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Hip fractures, nocturia, and nocturnal polyuria in the elderly
Archives of Gerontology and Geriatrics 43 (2006) 319–326 www.elsevier.com/locate/archger
Hip fractures, nocturia, and nocturnal polyuria in the elderly R. Asplund a,b,* b
a Centre of Public Health, Karolinska Institutet, SE-141 83 Huddinge, Sweden ¨ stersund, Sweden The Research and Development Unit, Ja¨mtland County Council, SE-831 25 O
Received 17 August 2005; accepted 12 December 2005 Available online 7 February 2006
Abstract This study was undertaken to evaluate the relation between hip fractures and nocturnal micturition habits in elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects. The mean (S.D.) ages of the men and women were 73.0 6.0 and 72.6 6.7 years, respectively. A hip fracture during the past five years had occurred in 97 (3.9%) of the men and 175 (4.6%) of the women and the occurrence increased with increasing age in both sexes. In both men and women nocturnal micturition increased with age. Among men, passing of subjectively large amounts of urine at night was reported to occur never or very seldom in 63.3% and rather seldom, rather often, and very often in 21.9%, 12.7%, and 2.1%, respectively. The corresponding frequencies in women were 65.1%, 17.2%, 13.7%, and 3.9%, respectively. Multiple logistic regression analysis with sex, nocturia, and nocturnal voided volumes as independent variables and occurrence of hip fracture during the last five years as the dependent variable showed that the risk of having had a hip fracture was increased by nocturia three or more episodes versus two or fewer; odds ratio (OR) 1.8, confidence interval (CI) 1.1– 3.0, and by large nocturnal urine volumes, very often versus very seldom or never; (OR 3.5; CI 1.8–7.3). One can conclude that in these elderly subjects the risk of hip fractures during a five-year period was increased independently by increased nocturnal micturition and increased nocturnal urine output. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Fall injury; Hip fracture; Nocturia; Nocturnal polyuria; Sleep
1. Introduction Falls are a common problem in the elderly. One fourth of community-dwelling elderly people of ages 65–74 years and one third of those of ages 75 years and over suffer at least * Present address: Tallva¨gen 3, S-833 34 Stro¨msund, Sweden. Tel.: +46 670 100 07; fax: +46 63 16 56 26. E-mail addresses: [email protected], [email protected]. 0167-4943/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2005.12.002
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one fall during one year (Tideiksaar, 1996). One fourth of the falls occur at night and more than half of the night-time falls occur in relation to toilet visits (Jensen et al., 2002). The risk of falls is increased by increasing age and female gender (Stalenhoef et al., 2000; Donmez and Gokkoca, 2003) and also by insufficient light and incomplete ˚ berg, 1992), and by environmental awakening when getting up at night (Asplund and A factors, for example, wet spots on the floor and slippery floors or uneven carpets. One common and deleterious consequence of falls is hip fractures. The incidence of these injuries is expected to increase as a consequence of the aging of the population worldwide (Lefauveau and Fardellone, 2004). The estimated lifetime risk of a hip fracture has been calculated to be one in 18 in men and one in seven in women (Boonen et al., 1996). By the age of 90 years the accumulated risk of having sustained a hip fracture is one in four in women and one in eight in men (Armstrong and Wallace, 1994). Owing to their high prevalence, hip fractures are very costly to the society. In a recent study, the average cost in association with hospital care for one patient, including ward costs, operative costs, and investigations was estimated to be £12,163 (about 18,000 Euro). The costs of rehabilitation were not included in this assessment (Lawrence et al., 2005). Thus, in addition to the suffering caused to the patient, there are many good reasons for increasing the understanding of the mechanisms underlying the occurrence of hip fractures and for finding methods to reduce the risk of fall injuries in general and hip fractures in particular in the elderly. Some studies have indicated that there is an increased risk of fall injuries in association with urinary tract symptoms, such as urinary incontinence (Tromp et al., 1998; Wagner et al., 2002) and overactive bladder (Wagner et al., 2002). In a questionnaire survey among elderly men and women in Sweden it was found at a followup that the death rates in those who four and a half years previously had reported having three or more episodes of nocturnal micturition were twice as high as those among the whole groups of men and women, respectively, after adjustments for age, sex, cardiac diseases, diabetes, and stroke (Asplund, 1999). It was presumed that a considerable proportion of the deaths was attributable to fall injuries, directly or as a contributory cause, since in men and women with 3 nocturnal voids who died during the study period had reported giddiness in their questionnaires more than twice as often as those with two or fewer nocturnal voids (Asplund, 1999). Reports on poor balance showed a similar pattern. The present study was undertaken to assess the occurrence of hip fractures in relation to nocturnal micturition habits in a group of elderly men and women.
2. Subjects and methods 2.1. Current study group All 10,216 members of the pensioners’ association SPF in the Swedish counties of Va¨sterbotten and Norrbotten were asked to participate in an extensive questionnaire survey. A further questionnaire was sent to those who did not respond within one month.
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2.2. The questionnaire This is a report based on an extensive questionnaire survey, containing questions on age, marital status, general state of health, habits, diseases, symptoms, and medication. In the present study the relation between hip fractures, nocturnal micturition, and large nocturnal urine output was addressed. The occurrence of hip fractures was assessed by the statement: ‘‘I have had a hip fracture during the last five years’’ with the alternative answers ‘‘yes’’ or ‘‘no’’. Those who had had more than one hip fracture were not analyzed separately, as these subjects were too few (four men and seven women). The number of nocturnal micturition episodes was reported and for the analysis, groups with ‘‘no’’, ‘‘one’’, ‘‘two’’ and ‘‘ three’’ episodes were formed. To assess the occurrence of subjectively large amounts of urine at night, the men and women were asked to respond to the statement: ‘‘I am passing large amounts of urine at night’’. Here there were four response alternatives: ‘‘very seldom or never’’, ‘‘rather seldom’’, ‘‘rather often’’ or ‘‘very often’’. 2.3. Statistical methods Standard methods were used for calculating mean values and standard deviations. Group comparisons of non-numerical data were made with the chi-square test. For comparing frequencies, odds ratios (OR) with a 95% confidence interval (CI) were calculated. For simultaneous evaluation of the influence of more than one independent variable on a dependent variable, logistic regression analysis (StatView 5.0 for the Macintosh) was performed.
3. Results 3.1. General The questionnaire was completed initially by 4544 persons. After a reminder, a further 1559 answers were received. Thus, there were 6103 evaluable questionnaires, of which 39.5% were from men. The response rate was 61.3%. The ages (mean S.D.) of the male and female participants were 73.0 6.0 and 72.6 6.7 years, respectively. Twenty-six percent of the men and 57% of the women were living alone. 3.2. Nocturnal micturition and nocturnal urine output In both men and women nocturnal micturition increased with increasing age (Table 1). Among the men, 63.3% reported that they never or very seldom passed large amounts of urine at night and the proportion reporting that this occurred rather seldom, rather often, and very often were 21.9%, 12.7%, and 2.1%, respectively. The corresponding frequencies in women were 65.1%, 17.2%, 13.7%, and 3.9%, respectively.
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Table 1 The distribution (%) of nocturnal micturition episodes in different age groups in men and women ( p < 0.0001 for both sexes) Age
None
One
Two
Three
Men –70 70–79 80–
30.7 22.1 26.4
49.5 46.4 41.5
15.0 23.4 24.9
4.8 8.1 7.3
Women –70 70–79 80–
33.4 30.0 29.3
47.3 44.8 41.4
14.4 17.3 19.5
4.9 7.9 9.8
3.3. Hip fractures, nocturnal micturition, and voided volumes A hip fracture during the past five years had occurred in 97 (3.9%) of the men and in 175 (4.6%) of the women and this occurrence increased with increasing age in both sexes (Fig. 1). The occurrence of hip fractures is increased in parallel with an increasing number of episodes of nocturnal micturition (Fig. 2) and with an increasing frequency of occasions in which large amounts of urine were passed at night (Fig. 3). 3.4. Logistic regression analysis A multiple logistic regression analysis with sex, nocturia, and nocturnal voided volumes as independent variables and having had a hip fracture during the last five years as the dependent variable was performed. The risk of having had a hip fracture was increased by nocturia, three or more episode versus two or fewer, (OR 1.8; CI 1.1–3.0), and large nocturnal urine volumes, very often versus very seldom or never (OR 3.5; CI 1.8–7.3).
Fig. 1. The five-year prevalence (%) of hip fractures in relation to age in men (white bars) and women (dotted bars).
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Fig. 2. The five-year prevalence (%) of hip fractures in relation to the number of nocturnal micturition episodes in men (white bars) and women (dotted bars).
Fig. 3. The five-year prevalence (%) of hip fractures in relation to the occurrence of subjectively very large nocturnal urine output in men (white bars) and women (dotted bars).
Reports on having large urine volumes rather seldom and rather often were not associated with any independent increase in hip fracture. Sex was also deleted by the logistic model.
4. Discussion In the present study it was found that a history of hip fractures during the last five years was increased about two-fold with every decade of age (Fig. 1) and was also increased in a stepwise manner, in parallel with an increasing number of episodes of nocturnal micturition (Fig. 2). An increase in fall injuries in elderly people with nocturia has been reported
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previously, but often in those who were also troubled by incontinence (Steiner et al., 1997; Palmer et al., 2002). In a study by Stewart et al. (1992) it was found that fall injuries were increased during a five-year observation period in 520 men and 988 women who reported at least two micturition episodes during the night (OR 1.84; CI 1.05–3.22) and were further increased in subjects reporting more than three nocturia events (OR 2.15; CI 1.04–4.44). An increase occurrence of bone fractures was not observed. The design of their study showed similarities to the present one but there were also differences. The number of participants was about one fourth of that in the present study, and the number of men, in particular was even much smaller than the present number. Their study group was also seven years older and there is no information on health, habits, or locomotive capacity (Stewart et al., 1992). One important question in the interpretation of these data is whether or not there is correspondence between the true occurrence of hip fractures and the accuracy of the subjects’ recall of them. No report addressing this issue has been found, but in a study on occupational injuries among older workers the influence of the length of the recall period on recall of injuries was rather low (Zwerling et al., 1995). As hip fractures are experiences often accompanied by severe pain, hospital care, and long-term rehabilitation, it seems reasonable to assume that such fractures will be correctly remembered in most cases. If reports on hip fractures were not correctly answered in the questionnaire, it seems more probable that they would have been under- than over-reported. This may be consistent with the conclusion that the relation between nocturia and hip fractures may be underestimated, rather than the contrary. It could be presumed that nocturia would be associated with an increased risk of hip fractures as a consequence of more frequent visits to the toilet at night. The increased number of occasions of getting up at night, often in a state of tiredness and sometimes orthostatic hypotension, with poor light, walking on slippery floors, and possibly uneven carpets all increase the risk of falls, for obvious reasons. Reports on passing of large amounts of urine at night were also associated with increased reports on hip fractures (Fig. 3). The multiple logistic regression analysis revealed that there was an increased risk of hip fractures in those who were very often troubled by large nocturnal urine volumes, after the influence of nocturia had been taken into account. Nocturia is caused by an increased nocturnal urine output, a reduced bladder capacity or a combination of the two (Weiss and Blaivas, 2003). An increase in the nocturnal urine output is not always associated with an increased number of episodes nocturnal micturition, although the two conditions are closely interrelated. If the bladder capacity is increased, the influence by increased nocturnal urine output on nocturnal micturition may be small or absent. Nocturnal polyuria is associated with multiple symptoms that can be attributed to a negative fluid balance, such as dryness in the eyes, mouth and throat, a burning mouth, and giddiness (Asplund, 2004, 2005a,b). These symptoms are present not only at night but during the whole 24-h period. Particularly in patients experiencing autonomic failure with nocturnal polyuria, a pronounced postural decrease in nocturnal blood pressure is a common finding (Mathias et al., 1986). In a study on the relation between nocturia and death rate in elderly men it was found that among those who had died within a study period of 54 months and had had at least three episodes of micturition per night both giddiness and poor balance in the daytime were more common than in men with two or fewer such episodes. Similarly, in women
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giddiness, poor balance, dry mouth, dry eyes, and thirst were all more common in the former category (Asplund, 1999). The present study did not allow any analysis of the time in the 24-h period at which the hip fractures occurred. The increase in daytime symptoms mentioned above indicates that the disturbance of the fluid balance attributable to nocturnal polyuria may increase the risk of fall injuries during the day and not only in connection with nocturnal toilet visits. Superficial and fragmented sleep associated with nocturnal voiding results in daytime sleepiness and balance impairment, which also increase the risk ˚ berg, 1992). of fall injuries (Asplund and A In the previously mentioned study (Asplund, 1999) it was also found that among nocturnal symptoms, a need to drink was more common in those men and women with nocturia who had died within the study period. The risk of nocturnal fall injuries risk may, therefore, be increased not only by nocturnal toilet visits but also, partly, by getting out of bed to drink. Moreover, it has been shown previously that leg tinglings and muscle cramps in the calves, indicative of disturbances in the fluid and electrolyte balance due to nocturnal polyuria, are increased in nocturia. These symptoms may also be sleep disturbing and ˚ berg, 1992). increase the need to get out of bed at night (Asplund and A In efforts to prevent of hip fractures in the elderly, many measures have been suggested, including consideration of common risks such as stairs, carpets, illumination conditions at night, inappropriate footwear (e.g. slippers), and obstacles in the living space (Lefauveau and Fardellone, 2004). Additionally, reduction of nocturia and nocturnal polyuria should be considered in an attempt to reduce the risk of falls in elderly persons, in whom multiple falls might occur as a result of an increased need to get up at night to void or drink. Both distressing urinary urgency and nocturnal polyuria can be reduced by pharmacological treatment (Asplund et al., 1999; Rembratt et al., 2003; Yoshida et al., 2004). To summarize, in these elderly subjects the risk of sustaining hip fractures during a fiveyear period was increased independently by an increased number of episodes of nocturnal micturition and an increased nocturnal urine output. Nocturnal micturition may increase the risk of hip fractures above all through a greater need to get out of bed at night in a state of sleepiness and sometimes giddiness. The increased nocturnal urine output may increase the risk of hip fractures by its propensity to create a negative fluid and electrolyte balance with giddiness and balance impairment as a result. Thirst and increased dryness of the mucous membranes in the mouth and throat, leading to an increased need for drinking, particularly at night, may represent additional risk factors.
References Armstrong, A.L., Wallace, W.A., 1994. The epidemiology of hip fractures and methods of prevention. Acta Orthop. Belg. 60, 85–101. Asplund, R., 1999. Mortality in the elderly in relation to nocturnal micturition. Br. J. Urol. 84, 297–301. Asplund, R., 2004. Nocturia in the elderly in relation to thirst, dry mouth and dry eyes. Can. J. Urol. 11, 1749– 1753. Asplund, R., 2005a. Nocturnal giddiness in relation to nocturia and other symptoms and to medication in the elderly. Arch. Gerontol. Geriatr. 40, 103–111. Asplund, R., 2005b. Nocturia and the burning mouth syndrome in elderly men and women. Arch. Gerontol. Geriatr. 41, 255–260.
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˚ berg, H., 1992. Health of the elderly with regard to sleep and nocturnal micturition. Scand. J. Prim. Asplund, R., A Health Care 10, 98–104. Asplund, R., Sundberg, B., Bengtsson, P., 1999. Oral desmopressin for nocturnal polyuria in elderly subjects: a double-blind, placebo-controlled, and randomized exploratory study. Br. J. Urol. Int. 83, 591–595. Boonen, S., Broos, P., Dequeker, J., 1996. Age-related factors in the pathogenesis of senile (type II) femoral neck fractures. An integrated view. Am. J. Orthop. 25, 198–204. Donmez, L., Gokkoca, Z., 2003. Accident profile of older people in Antalya City Center, Turkey. Arch. Gerontol. Geriatr. 37, 99–108. Jensen, J., Lundin-Olsson, L., Nyberg, L., Gustafson, Y., 2002. Falls among frail older people in residential care. Scand. J. Public Health 30, 54–61. Lawrence, T.M., White, C.T., Wenn, R., Moran, C.G., 2005. The current hospital costs of treating hip fractures. Injury 36, 88–92. Lefauveau, P., Fardellone, P., 2004. Extraskeletal risk factors for fractures of the proximal femur. Joint Bone Spine 71, 14–17. Mathias, C.J., Fosbraey, P., da Costa, D.F., Thornley, A., Bannister, R., 1986. The effect of desmopressin on nocturnal polyuria, overnight weight loss, and morning postural hypotension in patients with autonomic failure. Br. Med. J. 293, 353–354. Palmer, M.H., Baumgarten, M., Langenberg, P., Carson, J.L., 2002. Risk factors for hospital-acquired incontinence in elderly female hip fracture patients. J. Gerontol. A Biol. Sci. Med. Sci. 57, M672–M677. ˚ ., Norgaard, J.P., Andersson, K.E., 2003. Desmopressin in elderly patients with nocturia: short-term Rembratt, A safety and effects on urine output, sleep and voiding patterns. Br. J. Urol. Int. 91, 642–646. Stalenhoef, P.A., Diederiks, J.P., Knottnerus, J.A., de Witte, L.P., Crebolder, H.F., 2000. The construction of a patient record-based risk model for recurrent falls among elderly people living in the community. Fam. Pract. 17, 490–496. Steiner, J.F., Kramer, A.M., Eilertsen, T.B., Kowalsky, J.C., 1997. Development and validation of a clinical prediction rule for prolonged nursing home residence after hip fracture. J. Am. Geriatr. Soc. 45, 1510–1514. Stewart, R.B., Moore, M.T., May, F.E., Marks, R.G., Hale, W.E., 1992. Nocturia: a risk factor for falls in the elderly. J. Am. Geriatr. Soc. 40, 1217–1220. Tideiksaar, R., 1996. Preventing falls: how to identify risk factors, reduce complications. Geriatrics 51, 43–55. Tromp, A.M., Smit, J.H., Deeg, D.J., Bouter, L.M., Lips, P., 1998. Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J. Bone Miner. Res. 13, 1932–1939. Wagner, T.H., Hu, T.W., Bentkover, J., LeBlanc, K., Stewart, W., Corey, R., Zhou, Z., Hunt, T., 2002. Healthrelated consequences of overactive bladder. Am. J. Manag. Care 8 (Suppl. 19), S598–S607. Weiss, J.P., Blaivas, J.G., 2003. Nocturia. Curr. Urol. Rep. 4, 362–366. Yoshida, M., Miyamae, K., Iwashita, H., Otani, M., Inadome, A., 2004. Management of detrusor dysfunction in the elderly: changes in acetylcholine and adenosine triphosphate release during aging. Urology 63, 17–23. Zwerling, C., Sprince, N.L., Wallace, R.B., Davis, C.S., Whitten, P.S., Heeringa, S.G., 1995. Effect of recall period on the reporting of occupational injuries among older workers in the Health and Retirement Study. Am. J. Ind. Med. 28, 583–590.
Hip fractures, nocturia, and nocturnal polyuria in the elderly R. Asplund a,b,* b
a Centre of Public Health, Karolinska Institutet, SE-141 83 Huddinge, Sweden ¨ stersund, Sweden The Research and Development Unit, Ja¨mtland County Council, SE-831 25 O
Received 17 August 2005; accepted 12 December 2005 Available online 7 February 2006
Abstract This study was undertaken to evaluate the relation between hip fractures and nocturnal micturition habits in elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects. The mean (S.D.) ages of the men and women were 73.0 6.0 and 72.6 6.7 years, respectively. A hip fracture during the past five years had occurred in 97 (3.9%) of the men and 175 (4.6%) of the women and the occurrence increased with increasing age in both sexes. In both men and women nocturnal micturition increased with age. Among men, passing of subjectively large amounts of urine at night was reported to occur never or very seldom in 63.3% and rather seldom, rather often, and very often in 21.9%, 12.7%, and 2.1%, respectively. The corresponding frequencies in women were 65.1%, 17.2%, 13.7%, and 3.9%, respectively. Multiple logistic regression analysis with sex, nocturia, and nocturnal voided volumes as independent variables and occurrence of hip fracture during the last five years as the dependent variable showed that the risk of having had a hip fracture was increased by nocturia three or more episodes versus two or fewer; odds ratio (OR) 1.8, confidence interval (CI) 1.1– 3.0, and by large nocturnal urine volumes, very often versus very seldom or never; (OR 3.5; CI 1.8–7.3). One can conclude that in these elderly subjects the risk of hip fractures during a five-year period was increased independently by increased nocturnal micturition and increased nocturnal urine output. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Fall injury; Hip fracture; Nocturia; Nocturnal polyuria; Sleep
1. Introduction Falls are a common problem in the elderly. One fourth of community-dwelling elderly people of ages 65–74 years and one third of those of ages 75 years and over suffer at least * Present address: Tallva¨gen 3, S-833 34 Stro¨msund, Sweden. Tel.: +46 670 100 07; fax: +46 63 16 56 26. E-mail addresses: [email protected], [email protected]. 0167-4943/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2005.12.002
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one fall during one year (Tideiksaar, 1996). One fourth of the falls occur at night and more than half of the night-time falls occur in relation to toilet visits (Jensen et al., 2002). The risk of falls is increased by increasing age and female gender (Stalenhoef et al., 2000; Donmez and Gokkoca, 2003) and also by insufficient light and incomplete ˚ berg, 1992), and by environmental awakening when getting up at night (Asplund and A factors, for example, wet spots on the floor and slippery floors or uneven carpets. One common and deleterious consequence of falls is hip fractures. The incidence of these injuries is expected to increase as a consequence of the aging of the population worldwide (Lefauveau and Fardellone, 2004). The estimated lifetime risk of a hip fracture has been calculated to be one in 18 in men and one in seven in women (Boonen et al., 1996). By the age of 90 years the accumulated risk of having sustained a hip fracture is one in four in women and one in eight in men (Armstrong and Wallace, 1994). Owing to their high prevalence, hip fractures are very costly to the society. In a recent study, the average cost in association with hospital care for one patient, including ward costs, operative costs, and investigations was estimated to be £12,163 (about 18,000 Euro). The costs of rehabilitation were not included in this assessment (Lawrence et al., 2005). Thus, in addition to the suffering caused to the patient, there are many good reasons for increasing the understanding of the mechanisms underlying the occurrence of hip fractures and for finding methods to reduce the risk of fall injuries in general and hip fractures in particular in the elderly. Some studies have indicated that there is an increased risk of fall injuries in association with urinary tract symptoms, such as urinary incontinence (Tromp et al., 1998; Wagner et al., 2002) and overactive bladder (Wagner et al., 2002). In a questionnaire survey among elderly men and women in Sweden it was found at a followup that the death rates in those who four and a half years previously had reported having three or more episodes of nocturnal micturition were twice as high as those among the whole groups of men and women, respectively, after adjustments for age, sex, cardiac diseases, diabetes, and stroke (Asplund, 1999). It was presumed that a considerable proportion of the deaths was attributable to fall injuries, directly or as a contributory cause, since in men and women with 3 nocturnal voids who died during the study period had reported giddiness in their questionnaires more than twice as often as those with two or fewer nocturnal voids (Asplund, 1999). Reports on poor balance showed a similar pattern. The present study was undertaken to assess the occurrence of hip fractures in relation to nocturnal micturition habits in a group of elderly men and women.
2. Subjects and methods 2.1. Current study group All 10,216 members of the pensioners’ association SPF in the Swedish counties of Va¨sterbotten and Norrbotten were asked to participate in an extensive questionnaire survey. A further questionnaire was sent to those who did not respond within one month.
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321
2.2. The questionnaire This is a report based on an extensive questionnaire survey, containing questions on age, marital status, general state of health, habits, diseases, symptoms, and medication. In the present study the relation between hip fractures, nocturnal micturition, and large nocturnal urine output was addressed. The occurrence of hip fractures was assessed by the statement: ‘‘I have had a hip fracture during the last five years’’ with the alternative answers ‘‘yes’’ or ‘‘no’’. Those who had had more than one hip fracture were not analyzed separately, as these subjects were too few (four men and seven women). The number of nocturnal micturition episodes was reported and for the analysis, groups with ‘‘no’’, ‘‘one’’, ‘‘two’’ and ‘‘ three’’ episodes were formed. To assess the occurrence of subjectively large amounts of urine at night, the men and women were asked to respond to the statement: ‘‘I am passing large amounts of urine at night’’. Here there were four response alternatives: ‘‘very seldom or never’’, ‘‘rather seldom’’, ‘‘rather often’’ or ‘‘very often’’. 2.3. Statistical methods Standard methods were used for calculating mean values and standard deviations. Group comparisons of non-numerical data were made with the chi-square test. For comparing frequencies, odds ratios (OR) with a 95% confidence interval (CI) were calculated. For simultaneous evaluation of the influence of more than one independent variable on a dependent variable, logistic regression analysis (StatView 5.0 for the Macintosh) was performed.
3. Results 3.1. General The questionnaire was completed initially by 4544 persons. After a reminder, a further 1559 answers were received. Thus, there were 6103 evaluable questionnaires, of which 39.5% were from men. The response rate was 61.3%. The ages (mean S.D.) of the male and female participants were 73.0 6.0 and 72.6 6.7 years, respectively. Twenty-six percent of the men and 57% of the women were living alone. 3.2. Nocturnal micturition and nocturnal urine output In both men and women nocturnal micturition increased with increasing age (Table 1). Among the men, 63.3% reported that they never or very seldom passed large amounts of urine at night and the proportion reporting that this occurred rather seldom, rather often, and very often were 21.9%, 12.7%, and 2.1%, respectively. The corresponding frequencies in women were 65.1%, 17.2%, 13.7%, and 3.9%, respectively.
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Table 1 The distribution (%) of nocturnal micturition episodes in different age groups in men and women ( p < 0.0001 for both sexes) Age
None
One
Two
Three
Men –70 70–79 80–
30.7 22.1 26.4
49.5 46.4 41.5
15.0 23.4 24.9
4.8 8.1 7.3
Women –70 70–79 80–
33.4 30.0 29.3
47.3 44.8 41.4
14.4 17.3 19.5
4.9 7.9 9.8
3.3. Hip fractures, nocturnal micturition, and voided volumes A hip fracture during the past five years had occurred in 97 (3.9%) of the men and in 175 (4.6%) of the women and this occurrence increased with increasing age in both sexes (Fig. 1). The occurrence of hip fractures is increased in parallel with an increasing number of episodes of nocturnal micturition (Fig. 2) and with an increasing frequency of occasions in which large amounts of urine were passed at night (Fig. 3). 3.4. Logistic regression analysis A multiple logistic regression analysis with sex, nocturia, and nocturnal voided volumes as independent variables and having had a hip fracture during the last five years as the dependent variable was performed. The risk of having had a hip fracture was increased by nocturia, three or more episode versus two or fewer, (OR 1.8; CI 1.1–3.0), and large nocturnal urine volumes, very often versus very seldom or never (OR 3.5; CI 1.8–7.3).
Fig. 1. The five-year prevalence (%) of hip fractures in relation to age in men (white bars) and women (dotted bars).
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Fig. 2. The five-year prevalence (%) of hip fractures in relation to the number of nocturnal micturition episodes in men (white bars) and women (dotted bars).
Fig. 3. The five-year prevalence (%) of hip fractures in relation to the occurrence of subjectively very large nocturnal urine output in men (white bars) and women (dotted bars).
Reports on having large urine volumes rather seldom and rather often were not associated with any independent increase in hip fracture. Sex was also deleted by the logistic model.
4. Discussion In the present study it was found that a history of hip fractures during the last five years was increased about two-fold with every decade of age (Fig. 1) and was also increased in a stepwise manner, in parallel with an increasing number of episodes of nocturnal micturition (Fig. 2). An increase in fall injuries in elderly people with nocturia has been reported
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previously, but often in those who were also troubled by incontinence (Steiner et al., 1997; Palmer et al., 2002). In a study by Stewart et al. (1992) it was found that fall injuries were increased during a five-year observation period in 520 men and 988 women who reported at least two micturition episodes during the night (OR 1.84; CI 1.05–3.22) and were further increased in subjects reporting more than three nocturia events (OR 2.15; CI 1.04–4.44). An increase occurrence of bone fractures was not observed. The design of their study showed similarities to the present one but there were also differences. The number of participants was about one fourth of that in the present study, and the number of men, in particular was even much smaller than the present number. Their study group was also seven years older and there is no information on health, habits, or locomotive capacity (Stewart et al., 1992). One important question in the interpretation of these data is whether or not there is correspondence between the true occurrence of hip fractures and the accuracy of the subjects’ recall of them. No report addressing this issue has been found, but in a study on occupational injuries among older workers the influence of the length of the recall period on recall of injuries was rather low (Zwerling et al., 1995). As hip fractures are experiences often accompanied by severe pain, hospital care, and long-term rehabilitation, it seems reasonable to assume that such fractures will be correctly remembered in most cases. If reports on hip fractures were not correctly answered in the questionnaire, it seems more probable that they would have been under- than over-reported. This may be consistent with the conclusion that the relation between nocturia and hip fractures may be underestimated, rather than the contrary. It could be presumed that nocturia would be associated with an increased risk of hip fractures as a consequence of more frequent visits to the toilet at night. The increased number of occasions of getting up at night, often in a state of tiredness and sometimes orthostatic hypotension, with poor light, walking on slippery floors, and possibly uneven carpets all increase the risk of falls, for obvious reasons. Reports on passing of large amounts of urine at night were also associated with increased reports on hip fractures (Fig. 3). The multiple logistic regression analysis revealed that there was an increased risk of hip fractures in those who were very often troubled by large nocturnal urine volumes, after the influence of nocturia had been taken into account. Nocturia is caused by an increased nocturnal urine output, a reduced bladder capacity or a combination of the two (Weiss and Blaivas, 2003). An increase in the nocturnal urine output is not always associated with an increased number of episodes nocturnal micturition, although the two conditions are closely interrelated. If the bladder capacity is increased, the influence by increased nocturnal urine output on nocturnal micturition may be small or absent. Nocturnal polyuria is associated with multiple symptoms that can be attributed to a negative fluid balance, such as dryness in the eyes, mouth and throat, a burning mouth, and giddiness (Asplund, 2004, 2005a,b). These symptoms are present not only at night but during the whole 24-h period. Particularly in patients experiencing autonomic failure with nocturnal polyuria, a pronounced postural decrease in nocturnal blood pressure is a common finding (Mathias et al., 1986). In a study on the relation between nocturia and death rate in elderly men it was found that among those who had died within a study period of 54 months and had had at least three episodes of micturition per night both giddiness and poor balance in the daytime were more common than in men with two or fewer such episodes. Similarly, in women
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giddiness, poor balance, dry mouth, dry eyes, and thirst were all more common in the former category (Asplund, 1999). The present study did not allow any analysis of the time in the 24-h period at which the hip fractures occurred. The increase in daytime symptoms mentioned above indicates that the disturbance of the fluid balance attributable to nocturnal polyuria may increase the risk of fall injuries during the day and not only in connection with nocturnal toilet visits. Superficial and fragmented sleep associated with nocturnal voiding results in daytime sleepiness and balance impairment, which also increase the risk ˚ berg, 1992). of fall injuries (Asplund and A In the previously mentioned study (Asplund, 1999) it was also found that among nocturnal symptoms, a need to drink was more common in those men and women with nocturia who had died within the study period. The risk of nocturnal fall injuries risk may, therefore, be increased not only by nocturnal toilet visits but also, partly, by getting out of bed to drink. Moreover, it has been shown previously that leg tinglings and muscle cramps in the calves, indicative of disturbances in the fluid and electrolyte balance due to nocturnal polyuria, are increased in nocturia. These symptoms may also be sleep disturbing and ˚ berg, 1992). increase the need to get out of bed at night (Asplund and A In efforts to prevent of hip fractures in the elderly, many measures have been suggested, including consideration of common risks such as stairs, carpets, illumination conditions at night, inappropriate footwear (e.g. slippers), and obstacles in the living space (Lefauveau and Fardellone, 2004). Additionally, reduction of nocturia and nocturnal polyuria should be considered in an attempt to reduce the risk of falls in elderly persons, in whom multiple falls might occur as a result of an increased need to get up at night to void or drink. Both distressing urinary urgency and nocturnal polyuria can be reduced by pharmacological treatment (Asplund et al., 1999; Rembratt et al., 2003; Yoshida et al., 2004). To summarize, in these elderly subjects the risk of sustaining hip fractures during a fiveyear period was increased independently by an increased number of episodes of nocturnal micturition and an increased nocturnal urine output. Nocturnal micturition may increase the risk of hip fractures above all through a greater need to get out of bed at night in a state of sleepiness and sometimes giddiness. The increased nocturnal urine output may increase the risk of hip fractures by its propensity to create a negative fluid and electrolyte balance with giddiness and balance impairment as a result. Thirst and increased dryness of the mucous membranes in the mouth and throat, leading to an increased need for drinking, particularly at night, may represent additional risk factors.
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