**6. Impact of urinary incontinence on the quality of life and its assessment**

UI produces a wide variety of negative effects on quality of life (QOL) for patients, from medical problems (falls, urinary tract infections, pressure sores, skin's complications, kidney failure, functional decline) to psychological (anxiety, depressive symptoms, insomnia, sadness, loneliness) or social limitations (social isolation, impact on ADL, need of social resources, nursing home admission). It is considered that impact on QOL is similar as produced by Diabetes Mellitus, Stroke or Arthritis (Ko et al, 2005). The patient's perception of the impact of their UI on their lifestyle is very important, and even mild UI has a significant on a patient's QOL, including the frailest population.

Since the last 10 years, the proposal from the International Continence Society and the World Health Organization is assessing the impact of urinary symptoms have on QOL**.** In fact, clinicians should be aware of it and they should take consideration of the adverse effects that even mild UI has on a patient's QOL. The urinary symptoms and their impact on patient's QOL can be assessed through different ways, but only the objective assessment based on validated questionnaires is the right form (Scottish Intercollegiate Guidelines Network, 2004).

The questionnaires have been validated for measuring the severity of the symptoms and also the impact on QOL. Patterns have been developed to analyze mainly urinary symptoms and other models to know the impact on QOL. Through the urinary questionnaires we can evaluate initial symptoms as well as impact on QOL, and the further modification of the urinary symptoms and their impact on QOL with our intervention.

A list of principal urinary questionnaires is presented in the table 5, and the main combined questionnaires (urinary and QOL) in the table 6.

One of the most practical questionnaires is the Short Form of the International Consultation Incontinence (table 7), which has been validated and translated to 30 languages, and has a high level of recommendation (grade A) by the International Continence Society (Gotoh, 2007).

impairment experienced UI (72 to 84 percent), and the proportion of incontinent patients increased significantly in relationship with the severity of impairment (from 60 percent in mild to 93 percent in severely demented). Physical dependency was associated with a higher prevalence of UI, from 26 percent in independent residents to 81 percent in disabled older patients (Shamliyan et al, 2007). However, few studies examined adjusted odds ratios of UI among residents in long term care independent of other confounding factors. Aging was associated with increased odds of UI by 3 percent per year to 24 percent per 5 years of age

In addition of the medical conditions, it is very important to highlight the role of the drugs that frequently received the older patients, on the urinary continence, as previously exposed

In summary, a poor health status with medical problems especially in the neurological area, a high consumption of drugs (diuretics, psychotropics) and a limited functional status are

**6. Impact of urinary incontinence on the quality of life and its assessment** 

UI produces a wide variety of negative effects on quality of life (QOL) for patients, from medical problems (falls, urinary tract infections, pressure sores, skin's complications, kidney failure, functional decline) to psychological (anxiety, depressive symptoms, insomnia, sadness, loneliness) or social limitations (social isolation, impact on ADL, need of social resources, nursing home admission). It is considered that impact on QOL is similar as produced by Diabetes Mellitus, Stroke or Arthritis (Ko et al, 2005). The patient's perception of the impact of their UI on their lifestyle is very important, and even mild UI has a

Since the last 10 years, the proposal from the International Continence Society and the World Health Organization is assessing the impact of urinary symptoms have on QOL**.** In fact, clinicians should be aware of it and they should take consideration of the adverse effects that even mild UI has on a patient's QOL. The urinary symptoms and their impact on patient's QOL can be assessed through different ways, but only the objective assessment based on validated questionnaires is the right form (Scottish Intercollegiate Guidelines

The questionnaires have been validated for measuring the severity of the symptoms and also the impact on QOL. Patterns have been developed to analyze mainly urinary symptoms and other models to know the impact on QOL. Through the urinary questionnaires we can evaluate initial symptoms as well as impact on QOL, and the further modification of the

A list of principal urinary questionnaires is presented in the table 5, and the main combined

One of the most practical questionnaires is the Short Form of the International Consultation Incontinence (table 7), which has been validated and translated to 30 languages, and has a high level of recommendation (grade A) by the International Continence Society (Gotoh, 2007).

main risks factors for loss of the continence in the frail elderly population.

significant on a patient's QOL, including the frailest population.

urinary symptoms and their impact on QOL with our intervention.

questionnaires (urinary and QOL) in the table 6.

(Shamliyan et al, 2007; Offermans et al, 2009).

above.

Network, 2004).


Table 5. Principal urinary questionnaires of incontinence

**International Consultation on Incontinence Questionnaire (ICIQ) (men and women) Bristol Female Lower Urinary Tract Symptoms International Continence Society SF (men) The Sickness Impact Profile (women) The Quality of Life of persons with Urinary Incontinence (I-QOL) (men and women) The Incontinence Impact Questionnaire (women) The Urogenital Distress Inventory (women)**

Table 6. Main combined urinary questionnaires (incontinence and impact on QOL)


Table 7. The International Consultation on Incontinence Questionnaire Short Form

Geriatric Urinary Incontinence – Special Concerns on the Frail Elderly 123


The physical examination should include an abdominal (for excluding a distended bladder or a pelvic mass), rectal (for evaluating the sphincter tone, the prostate size, the presence of impaction faecal) a basic neurological exam (especially gait and signs of focal lesions), a

The International Continence Society recommends also a post-void residual volume (PVR) measurement by a non-invasive method before to start medical or surgical treatment (Grade C of recommendation), although there are no evidence-based criteria for a high volume (DuBeau et al, 2010; Abrams et al, Markland et al, 2011). In general, PVR greater than 150-

Urine analysis should be done in all the incontinent frail patients, and it can be very useful to detect or rule out infection or hematuria. Although, results should be interpreted with caution due to the high percentage of asymptomatic bacteriuria in the older population (at least 20%). So, it is necessary to be sure of the relation between an abnormal urine analysis and the urinary symptoms (urgency, frequency, dysuria), in order to accept the clinical

Other laboratory tests (thyroid hormones, vitamin B12 or vitamin D levels) require an

Further step based on the findings of the basic approach we could detect some frail elderly who require further evaluation by different team of specialists (urologist, gynaecologist) or making certain techniques (ultrasounds, urodynamics) to complete the diagnostic process

In most frail older patients with incontinence, non-invasive diagnostic evaluation can be successfully done, and it will help to decide the conservative management of the patient. As previous mentioned, on the basis of basic step with its components (medical, pharmaceutical, functional, urinary diary, questionnaire of QOL, and a physical

In the table 8 are exposed the main criteria to refer a frail elderly to the specialist.

**8. Diagnostic approach of the urinary incontinence in the frail elderly** 

genital and pelvic examinations (cough stress test, prolapse evaluation).

diagnosis of urinary infection instead of asymptomatic bacteriuria.

recommendation of the voiding diaries is grade A.

200 ml is considered significant in frail older patients.

**7.1.2 Physical examination** 

**7.1.3 Basic investigations** 

individualized justification.

and provide the therapeutic alternatives.

**7.2 Further step** 

clinical evaluation. The information can be obtained from the patient or caregiver, and in the majority of the cases, probably a three day diary is usually sufficient. It is important to comment that in cases of high frailty, cognitive impairment or mental problems, we can use a register of the leakages and their amounts instead a formal diary. The level of
