Urinary Incontinence: Decreasing Risk and Optimizing Management by Engaging in Physical Activity and Other Health Behaviors*
Barbara Resnick, PhD, CRNP, FAAN, FAANP
Urinary incontinence is a complex clinical syndrome in aging, not a disease state that is easily treated and resolved. There are numerous factors that influence urinary incontinence, some of which are normal age changes and others associated with contributing disease states and lifestyle factors. Examples of contributory factors include but not limited to constipation, estrogen deficiency and atrophic vaginitis, benign prostatic hypertrophy, cystocele, nicotine, alcohol use, and sedentary lifestyles. Given the multiple causes of urinary incontinence, there are multiple opportunities for interventions to decrease episodes of incontinence. This paper provides the background and guidance for how to optimally change behavior in older adults to improve management of urinary incontinence.
Numerous factors influence UI among older adults including age related changes, medical problems (i.e., acute and chronic illness and medication management of disease states), functional changes (Khatutsky, 2013; Kraus, 2010) and behavioral factors (Burgio, Locher, Goode, et. al., 1998; Burgio, Locher, Goode, et. al. , 2001; Burrows, Meyn, Walters, & Weber, 2004; De Gagne, 2013; Griffiths, 2007; Harris, 2010; Hashim, 2006; Kafri, 2012; Pfisterer, Griffiths, Schafer, Resnick, 2006; Pfisterer, Griffiths, Rosenberg, et. al. , 2006; Resnick, Yalla, Laurino, 1989; Taylor, 2006; Yoshida, 2001). This paper will provide a brief overview of factors external to the lower urinary tract that contribute to urinary incontinence in older adults. It will also discuss a physical activity intervention to improve urinary incontinence.
Age related factors
With age the levator ani and coccygeus muscles that comprise the pelvic floor weaken. As the individual ages there is also a decrease in bladder sensation, decreased detrusor contractility, and urethral closure pressure, and an increase in nocturnal micturition, (i.e., emptying the bladder at night) (Pfisterer, Griffiths, Schafer, Resnick, 2006; Pfisterer, Griffiths, Rosenberg, et. al., 2006). There is not, however, a normal decrease in bladder capacity (Pfisterer, Griffiths, Schafer, Resnick, 2006). These age-related changes are not sufficient enough to cause urinary incontinence but rather, increase an older person’s vulnerability of becoming incontinent.
Some gender specific changes that influence UI include an age associated decrease in local estrogen levels in women. Estrogen decline contributes to both a decline in bladder sensation and detrusor motor function, and it can also cause atrophic vaginitis (i.e., inflammation of the vagina and surrounding tissue due to the lack of estrogen) which results in vaginal discomfort, burning, itching and associated dyspareunia (i.e., painful sexual intercourse), and a sense of urinary urgency. A cystocele (i.e., prolapse of the bladder into the vagina) can cause overflow of urine from the bladder, referred to as overflow incontinence (Thurmon, 2013). Although it is associated with “nerve stretch” the actual pathophysiology for why pelvic organ prolapse causes urinary incontinence is unclear (Burrows, et al., 2004). In men, obstruction in urinary flow can be due to external pressure on the urethra from benign enlargement of the prostate also called prostatic hypertrophy (BPH), or prostatic cancer.
Medical problems contributing to UI may be either acute or chronic. A symptomatic urinary tract infection can cause bladder irritation with a subsequent urge to urinate. Diabetes and hyperglycemic states can put individuals at risk for urinary tract infections and cause frequency by virtue of the hyperglycemic state of the urine. Cardiovascular disease such as heart failure and venous insufficiency contribute to urinary frequency and nocturia, (i.e., awakening to empty the bladder one or more times at night) both of which can result in urinary incontinence. This is particularly true for older adults who also have some mobility impairment.
Neurological disorders such as stroke can cause urinary incontinence due to central nervous system changes and inability to regulate urine flow. Dementia may result in urinary incontinence as the individual may lose the ability to recognize the urge to void and to follow the steps involved in toileting or voiding. Other diseases such as Parkinson’s disease can cause impairments in mobility and cognition and thereby contribute to urinary incontinence.
Constipation also increases the risk of experiencing urinary retention and overflow incontinence. Constipation commonly results in impacted stool in the rectum which elicits local, spontaneous neurogenic activity and can cause frequency and incontinence.
Medication management of chronic and acute problems may likewise contribute to and/or cause UI. Table 1 provides a list of medications that are likely to cause/contribute to UI.
Functional impairment is commonly noted with age and is associated with urinary incontinence (Friedman, 2006; Kafri, 2012; Khatutsky, 2013). Rates of incontinence are significantly higher among individuals with functional impairment, particularly impairments in toileting behavior as well as overall activities of daily living (Khatutsky, 2013). Specifically, approximately 20% of those with one or two impairments in activities of daily living (ADLs) reported urinary incontinence; about 33% of those with three or four impairments in activities of daily living reported incontinence; and more than 50% of those with five to six impairments in activities of daily living reported urinary incontinence. These rates are even higher among adults 85 years of age and older.
Lifestyle Factors That Influence UI
Several lifestyle factors and health behaviors impact UI including smoking, alcohol and caffeine intake, diet and weight management and amount of physical activity and subsequent maintenance of function. Caffeine causes both a diuretic effect as well as being a direct bladder irritant. Although the findings are not always consistent, there is some evidence that excessive caffeine (more than 4 cups a day) results in urgency and an involuntary desire to urinate (Gleason, 2013; Rai, 2012; Tettamanti, 2011). Although there are fewer studies, it appears that alcohol intake has an effect on urinary frequency, urgency, and complaints of incontinence (Zhu, 2009). It is not clear what the mechanism of action is associated with this association. It is possible that alcohol intake is associated with urinary incontinence because of the impact of alcohol, particularly excessive alcohol use, on cognitive and functional ability.
Smoking, whether current smoking or a history of smoking including heavy smoking (defined as more than 20 cigarettes a day), has been associated with urinary urgency and frequency but not with nocturia or stress urinary incontinence (Hannestad, 2000; Karon, 2009; Tahtinen, 2011). No studies have been conducted however to show that smoking cessation can improve urinary incontinence or any of the associated symptoms.
Although not specific to older adults, obesity [defined as a body mass index (BMI) that exceeds 30 kg/m2] has been noted to be a risk factor for urinary incontinence (Clinical Key, 2012; Hannestad, 2000; Karon, 2009). Obesity results in increased intra-abdominal pressure and weakening of the pelvic floor and urethral support structures, all of which contribute to urinary incontinence. For those who are described as overweight or obese there is some evidence to suggest that weight loss improves urinary incontinence (Kim, Yoshida, Suzuki, 2011; Olivera, 2012; Skelly, 2009; Wing, 2010). Specifically a 5% to 10% loss of body weight were noted to be sufficient for significant improvement in urinary incontinence (Wing, 2010). Ongoing research is looking at the relationships not only of weight loss but of the changes in dietary intake and impact that diet can have on urinary incontinence. One study has noted that decreasing saturated fat relative to polyunsaturated fat and decreasing total calories may account for the improvements noted in urinary incontinence among those that lose weight (Maserejian, 2010).
Physical Activity as an Intervention for Urinary Incontinence
Like obesity, sedentary behavior has been associated with risk of urinary incontinence (de Souza Santos Machado, Valadares, da Costa-Paiva, Moraes, & Pinto-Neto, 2012; Smith, 2010). Interventions that increase time spent in physical activity improve urinary incontinence (Brown, 2006; Schnelle, 2010). It is important, however, that the physical activity recommended for an older adult be appropriately geared toward decreasing episodes of incontinence and that it not cause incontinence. For example, high-impact physical activity (e.g, jumping rope) can actually increase episodes of urinary leakage. There is no evidence that this occurs in low impact, moderate level physical activity (Nygaard, 2005). Moreover, physical activity should be encouraged to help improve functional tasks such as transfers and ambulation so that getting to the bathroom, performing a toilet transfer, and managing clothes can be successfully achieved in a timely fashion.
Given the many contributing factors to UI and the high likelihood that older adults present with a mixed type of incontinence, multiple and combined treatment approaches will likely be needed. In addition, the use of conservative approaches such as weight loss when appropriate, smoking cessation, and exercise interventions and increased time spent in overall physical activity have been recommended as the best way in which to manage UI among older adults (Gomelsky, 2011; Karon, 2009; Roe, 2011). Across all of these approaches, increasing physical activity has the greatest likelihood of being beneficial to older adults. In addition to improving UI by directly strengthening pelvic floor muscles (Danforth, 2007), physical activity has the potential to increase functional ability and performance such as walking speed, gait and balance, toilet transfers, and endurance and thereby further decrease episodes of incontinence that occur simply due to insufficient time to get to the bathroom (Resnick, Galik, Gruber-Baldini, & Zimmerman S, 2011; Resnick et. al., 2009). Increasing time spent in physical activity also has important clinical benefits for older adults in terms of management of clinical problems such as hypertension, heart failure, and diabetes (American College of Sports Medicine and the American Heart Association, 2008; Calhoun et al., 2008; Gross, Anderson, Busby, Frith, & Panco, 2013).
Unfortunately, however, the majority of older adults do not engage in regular physical activity. A recent report noted that 32% of adults report engaging in no aerobic physical activity and the rate of participation is even lower for older adults with adherence rates in 2011 reported as low as 15% (Morbidity and Mortality Weekly Report, 2013). Rates of physical activity among nursing home residents and those in assisted living settings are even lower and the majority engage in no moderate level activity over the course of a 24 hour period(Resnick, Galik, Gruber-Baldini, & Zimmerman, 2010). It is critical, therefore, that health care providers implement interventions to increase physical activity among older adults with UI across all settings. Physical activity as a conservative approach should be used as a primary intervention for UI (that is, keeping continent older adults continent) as well as combined with other treatments that may have been initiated (e.g., medication management, surgical interventions).
Barriers and Challenges to Increasing Physical Activity Among Older Adults
Lack of adherence to participating in regular physical activity among older adults is due, in part, to lack of provider recommendations (Fallon, Wilcox, & Laken, 2006; Goldstein et al., 2006), lack of belief in the benefits associated with these behaviors (Hekler et al., 2008; Kaplan, Bhalodkar, Brown, White, & Brown, 2006; N. Kim, Talwalkar, & Holmboe, 2006), intrapersonal factors such as motivation, resilience, ability to overcome perceived and/or real barriers such as time, pain, comorbid conditions (Ailinger, Dear, & Holley-Wilcox, 1993; Belza et al., 2004; Sin, LoGerfo, Belza, & Cunningham, 2004) and access to resources such as safe walking paths or age appropriate exercise equipment (Cox, McKevitt, Rudd, & Wolfe, 2006; Hendrix, Riehle, & Egan, 2005; Travis, et. al., 2003).
Interventions to Increase Adherence to Physical Activity
Interventions that have been shown to increase adherence to physical activity include: easy accessibility to resources and opportunity to practice desired behaviors in a safe setting (Resnick, Galik, Gruber-Baldini, & Zimmerman, 2009); establishing positive attitudes and beliefs about the benefits of physical activity (Mishra, Gioia, Chilaress, Barnet, & Webster, 2011; Pepper, Carpenter, & DeVellis, 2012); using social supports to engage the individual in physical activities (Boutin-Foster, 2005; Jackson, 2006); implementing behavior oriented counseling and positive reinforcement (Drayton-Brooks & White, 2004; Kim, Ahn, Chon, Bowen, & Khan, 2005; Robbins, Rausch, Garcia, & Prestwood, 2004; Sisk et al., 2006; Thrasher, Campbell, & Oates, 2004); making therapeutic regimens simple and eliminating unpleasant sensations (Mishra, et al., 2011; Pepper, et al., 2012); removing barriers to access (Hekler, et al., 2008; Osterberg, & Blaschke, 2005); and providing ongoing verbal encouragement from a credible source(Osterberg & Blaschke, 2005; Petrilla, Benner, Battleman, Tierce, & Hazard, 2005; Schroeder, Fahey, Hay, Montgomery, & Peters, 2006; Vermeire, Hearnshaw, Van Royen, & Denekens, 2001).
Optimizing Physical Activity Benefits by Managing Sarcopenia
An important aspect of exercise interventions for UI is the ability of the older individual to gain muscle strength and improvement in function. Sarcopenia, once believed to be a normal age change, is a reduction in lean body mass and an increase in fat mass. Skeletal muscle and bone mass are the principal components of lean body mass. The reduction in lean body mass results in a decrease in strength, metabolic rate, aerobic capacity, and function. Sarcopenia is considered present among older adults who have muscle mass depletion, usually defined as two standard deviations below the mean muscle mass of younger persons. The causes are not due simply to aging. Instead the causes are multi-factorial and they include sedentary lifestyles, changes in endocrine function, chronic disease, inflammation, insulin resistance, and nutritional deficiencies. Thus interventions that decrease sarcopenia should also be considered to help older individuals with UI. In addition to engaging in some resistance exercise, to optimally stimulate muscle hypertrophy there must be a positive energy balance and adequate protein intake. There is no consensus on the amount of protein intake that an older individual should consume. Generally, however, it is recommended that intake of 1.0 to 1.3 g/kg/day of protein may facilitate muscle protein anabolism (Edwards, et. al., 2013). All meals for older adults should include a moderate amount of protein such as 4 ounces of meat; two eggs and a half cup of cottage cheese; half a can (3 ounces) of tuna fish; or a half cup of tofu (High Protein Food Options, 2013).
Changing Behavior to Decrease UI at the Individual Level
To work with individuals to increase physical activity, improve function, and decrease episodes of UI it is helpful to use a self-efficacy approach. Self-efficacy theory is based on a model of reciprocal determinism in which behavior, cognition, other personal factors, and the environment all operate interactively as determinants of each other. According to self-efficacy theory (Bandura, 1997; 2001; 2004; Bandura & Locke, 2003), human motivation and action are essentially regulated by forethought. This cognitive control of behavior is based on: (1) self-efficacy expectations, which are the individual’s belief in his or her ability to perform a course of action to attain a desired outcome; and (2) outcome expectancies, which are the beliefs that a certain outcome will occur through personal action. Efficacy expectations are dynamic and are both appraised and enhanced by four mechanisms: (1) enactive mastery or actually performing an activity; (2) verbal persuasion or encouragement to perform the activity; (3) vicarious experience which involves seeing like individuals perform an activity; and (4) positive or negative physiological and affective cues such as pain, fatigue, a sense of pride, or anxiety following performance of a specific activity. The theory of self-efficacy suggests that the stronger the individual’s efficacy expectations, the more likely he or she will initiate and persist with a given activity over time. Both self-efficacy and outcome expectations play an influential role in the adoption and maintenance of exercise, and other health behaviors, in older adults (Papandonatos, 2012; Toto, 2013; Tung, 2013). An older adult may have high self-efficacy expectations for exercise, for example, but if he or she does not believe the exercise will improve function or decrease episodes of UI, then it is unlikely that he or she will initiate and/or adhere to a regular exercise program.
To facilitate behavior change a simple face-to-face interview approach should be considered and could be incorporated into a Welcome to Medicare or Annual Wellness visit (Welcome to Medicare and Annual Medicare Visits, 2013). Guided by the theory of self-efficacy, a seven step approach was established and can be used to help providers identify a treatment plan (Table 2). The first step involves education about the complexity of UI at a level that older adults, including those with cognitive impairment, can understand. Providing information about the multiple causes of incontinence and the many different interventions that can decrease, if not eliminate, episodes of incontinence is useful. This can help the individual understand how increasing time spent in physical activity, weight loss, decreasing nicotine, alcohol and caffeine intake, and increasing protein intake are relevant activities to engage in to optimally manage incontinence episodes.
The second step involves assessing the behavior(s) that the individual needs to alter for him or her to decrease incontinence episodes. This might be smoking, excessive alcohol of caffeine intake, or exercise. Once the specific health behaviors are identified the provider can work with the individual to address Step three which involves setting goals around those behaviors. Both short and long term goals should be established. The short term goals should focus specifically on what the individual can do on a daily basis (e.g, walk to the dining room three times a day; decrease nicotine use to one cigarette a day). The long term goal might focus on reducing number of incontinence pads used daily or being able to go outside for a walk without an incontinent episode. Once goals are identified the barriers to achieving those goals can be considered as well as a plan put in place to begin to overcome the identified barriers. The remaining three steps focus on motivational aspects of the process and include ongoing verbal encouragement and a plan to reward the individual for any activities performed that address the behavioral goals identified.
Although UI in older adults is a complex syndrome with multiple causes, there are multiple options for interventions including physical activity interventions. Older adults need to be engaged in a process that involves working with their providers to decrease UI episodes using multiple approaches. Following a seven step approach to assessing and developing a plan of care can help older individuals safely and most effectively manage their UI and improve overall quality of life.