Perspectives in Disease Prevention and Health Promotion Urinary Incontinence Among Hospitalized Persons Aged 65 Years and Older -- United States, 1984 - 1987

Urinary incontinence (the involuntary loss of urine so severe as to have social or hygienic consequences (1)) affects at least 10 million persons in the United States. This problem is particularly common among persons aged greater than or equal to 65 years; in this age group, urinary incontinence is present in 15%-30% of community-dwelling (i.e., not hospitalized or in long-term-care institutions) persons, 15%-34% of those hospitalized in acute-care institutions, and about 50% of all long-term-care institution residents (2). This report summarizes a study of urinary incontinence among persons greater than or equal to 65 years of age discharged from hospitals in the United States from 1984 through 1987.

Data from the Health Care Financing Administration's Medicare Part A hospital discharge records were used to characterize the occurrence of urinary incontinence* among hospitalized persons by sex, race (white or black), age, type of urinary incontinence, and place of residence (3). Because a person may have been discharged from a hospital more than once during the period, a case was defined as the first mention of urinary incontinence on all discharge records for a person during the period. Denominators for calculating annual hospitalization rates were obtained from intercensal population estimates (4). Where appropriate, rates were age-standardized directly to the 1980 U.S. population aged greater than or equal to 65 years.

From 41,456,685 discharge records, 159,380 (0.38%) cases of urinary incontinence were identified. For all types of urinary incontinence, the annual age-standardized rate for women (16.6 per 10,000 population) was 64% higher than that for men (10.1 per 10,000 population). The age-standardized rate for whites (13.5 per 10,000 population) was 22% higher than that for blacks (11.1 per 10,000 population). Overall, rates were highest among white women, followed by black men, black women, and white men; rates increased directly with age (Table 1). For all patients aged less than 80 years, age-specific rates for all women exceeded those for all men.

Of the specific types of incontinence listed on the discharge records, 57% cited incontinence of urine; 43%, stress incontinence, female; and 0.2%, enuresis. Two percent of discharge records cited two or all three diagnoses. The highest annual age-standardized rate for incontinence of urine occurred among black men (13.6 per 10,000 population; 95% confidence interval (CI)=13.2-14.0), followed by white men (9.5; 95% CI=9.4-9.6), black women (6.8; 95% CI=6.5-7.0), and white women (6.1; 95% CI=6.0-6.2); rates also increased directly with age. For stress incontinence, the age-standardized rate among white women (10.7; 95% CI=10.6-10.8) was 3.7 times that among black women (3.0; 95% CI=2.8-3.1); rates varied inversely by age among white women, but for black women remained stable by age.

For all three types of urinary incontinence, annual hospitalization rates for women were highest in the northwest (including Alaska) and the central states (Table 2). For men, hospitalization rates were highest in the north central states. Rates for men and women were lowest in southern New England, the mid-Atlantic states, and Hawaii. Reported by: Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note:

The findings in this report indicate that annual hospital discharge rates for urinary incontinence that are based on Medicare records are substantially less than the reported prevalence of urinary incontinence among community-dwelling persons aged greater than or equal to 65 years or among those hospitalized in acute-care institutions (2). There are at least three potential explanations for this difference. First, this difference probably reflects underdiagnosis of urinary incontinence in the hospital and underreporting of urinary incontinence on medical discharge summaries. Second, because computerized Medicare hospitalization records include only the first five diagnoses from the discharge summary, some cases of urinary incontinence among persons with multiple diagnoses may have been excluded. Many of those patients who met the case definition for this study may have more severe manifestations of or were admitted to the hospital because of urinary incontinence (e.g., surgery for stress incontinence). Finally, use of denominators derived from U.S. census estimates, rather than from the Medicare-enrolled population, can lead to underestimating the Medicare hospitalization rates by as much as 27% (5).

The higher overall rates of urinary incontinence among women and the increase in rates with age are consistent with findings reported previously (2). The development of urinary incontinence may be associated with age-related changes in bladder capacity, residual urine, and involuntary bladder contractions (6). Overflow incontinence related to increased occurrence of benign prostatic hypertrophy and prostatic cancer may account for the higher rates for men than for women among persons greater than or equal to 80 years of age.

The geographic differences in hospitalization rates for urinary incontinence may reflect regional variations in 1) the diagnosis of the disorder and the recording of the diagnosis on discharge summaries, 2) the likelihood of hospital admission for urinary incontinence, or 3) the distribution of diseases and conditions that cause urinary incontinence (e.g., central nervous system disorders, or acontractile or neurogenic bladder associated with diabetes mellitus or spinal cord lesions). Because almost all persons aged greater than or equal to 65 years can obtain hospitalization under Medicare, differences in access to health care appear unlikely to account for these geographic variations.

Because urinary incontinence is prevalent among the elderly, and because the size of this age group continues to increase, the number of persons with urinary incontinence is likely to increase. One of the national health objectives for the year 2000 is to increase to at least 60% the proportion of primary-care providers for older adults who routinely evaluate persons aged greater than or equal to 65 years for urinary incontinence and other problems (7).

References

1. National Institutes of Health. Consensus conference: urinary incontinence in adults. JAMA 1989;261:2685-90.

2. Mohide AE. The prevalence and scope of urinary incontinence. Clin Geriatr Med 1986;2:639-55.

3. Health Care Financing Administration. Medicare part A hospitalizations (machine-readable public-use data tapes). Baltimore, Maryland: US Department of Health and Human Services, Public Health Service, 1984-1987.

4. Irwin R. Intercensal estimates of the population by age, sex, and race (machine-readable public-use data tape). Alexandria, Virginia: Demo-Detail, 1980-1988.

5. Fisher ES, Baron JA, Malenka DJ, Barrett J, Bubolz TA. Overcoming potential pitfalls in the use of Medicare data for epidemiologic research. Am J Public Health 1990;80:1487-90.

6. Ouslander JG. Urinary incontinence. In: Hazzard WR, Andres R, Bierman EL, Blass JP, eds. Principles of geriatric medicine and gerontology. 2nd ed. New York: McGraw-Hill, Inc., 1990:1123-42.

7. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:465-6; DHHS publication no. (PHS)91-50212. *International Classification of Diseases, Ninth Revision, Clinical Modification rubrics 307.6 (enuresis), 625.6 (stress incontinence, female), or 788.3 (incontinence of urine).

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