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Predictors of Institutionalization in an Older Population During a 13-Year Period: The Effect of Urge Incontinence

¹ Vaasa City Hospital, Finland.
² Tampere School of Public Health, University of Tampere, Finland.
³ Department of Urology, Tampere University Hospital and Medical School, University of Tampere, Finland.
⁴ Tampere University Hospital, Research Unit, University of Tampere, Finland.

	Abstract

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Background. Longitudinal data on predictors of institutionalization in random older populations are limited. The aim here was to identify predictors of institutionalization in an unselected older population during a period of 13 years with a special focus on the prognostic value of urge incontinence.

Methods. A population-based prospective survey was conducted involving 366 men and 409 women aged 60 years and older. Age-adjusted and multivariate Cox proportional hazards models were used to examine the predictive association of urge incontinence, living arrangements, neurological, cardiovascular, musculoskeletal, and other chronic diseases, activities of daily living (ADL) disability, and depressive symptoms with institutionalization separately in men and women.

Results. Adjusted for age, ADL disability and other chronic diseases predicted institutionalization in both men and women. Urge incontinence and depressive symptoms in men and living alone and cardiovascular diseases in women were also significant predictors. In multivariate analyses where all potential predictors were included simultaneously, age (RR [relative risk] 1.15; 95% CI [confidence interval] 1.10–1.19), urge incontinence (RR 3.07; 95% CI 1.24–7.59), and depressive symptoms (RR 1.22; 95% CI 1.00–1.48) remained significant predictors of institutionalization in men. In women, age (RR 1.15; 95% CI 1.12–1.19) and living alone (RR 2.02; 95% CI 1.27–3.21) were independent predictors.

Conclusions. In addition to age, urge incontinence and depressive symptoms in men and living alone in women are significant prognostic indicators of institutionalization. The greater prognostic value of urge incontinence in men compared with women emphasizes the importance of interventions aimed at promoting continence and coping with the problem both at the individual and caregiver levels especially among older men.

While several predictors for institutionalization have been identified in selected populations, such as people with dementia (1,2), relatively little longitudinal data is available about possible predictors in random older populations. However, in addition to age and female sex, functional disability and chronic diseases related to disability have been found to be major predictors for long-term institutional care (3–6). Dementing diseases are known to be among the most disabling diseases, which, sooner or later, are likely to bring the individual into a long-term facility (5,6). Cerebrovascular, cardiovascular, and musculoskeletal diseases have also been found to increase the risk of becoming institutionalized (4). In addition, living alone (7,8) and other indicators of inadequate family networks and social support (9,10) have been suggested to play an important role in the process of institutionalizing an older individual.

Institutionalization has been suggested as an outcome of urinary incontinence but, even here, population-based data are scarce. The most important type of incontinence among both institutionalized and community-dwelling older people is the urge type. The condition is by nature multifactorial, and the reasons for dysfunction may vary between the genders due to aging-related changes and aging-associated disease conditions of the lower urinary tract (11). In addition, urge incontinence may be associated with mobility and activities of daily living (ADL) disability (12,13).

Incontinence and behavioral symptoms can be burdensome to the caregiver (14,15), which might be one reason why they have been held to predict nursing home admission and institutionalization in dementia (16,17). Furthermore, poststroke incontinence has also been reported to predict long-term institutional care (18).

Previously, the association of urinary incontinence and the likelihood of becoming institutionalized in a general aged population was explained by dementia (19). Thom and colleagues reported that medically recognized urinary incontinence increased the risk of hospitalization and admission to a nursing home independent of age, gender, and presence of other disease conditions, including dementia and cerebrovascular diseases (20). However, living arrangements and disability were not adjusted for in these studies.

The goal here was to identify predictors of institutionalization among older people over a 13-year period. Our special focus was on whether urge incontinence is an independent predictor of institutionalization. Definitions for cognitive impairment or dementia were not included in the original design of the survey and therefore could not be adjusted for; instead, living arrangements, self-reported cardiovascular, neurological, musculoskeletal, and other chronic diseases, ADL disability, and depressive symptoms were taken into account in the analyses. Since both living conditions and nature of urinary symptoms in old age differ between men and women, the analyses were conducted separately for both genders.

	Methods

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Material
The baseline data come from the second wave of the Tampere Longitudinal Study on Ageing (TamELSA), a population-based prospective study of living conditions, health, functioning, life styles, and use of services among older people in the city of Tampere, Finland (21,22). The design and sample for the study have been described in greater detail elsewhere (21). Briefly, in 1989, a total of 1036 persons aged 60–99 years were eligible to be interviewed face to face, using a structured questionnaire. The response rate was 80%. After exclusion of 53 subjects already living in institutions and 3 subjects without data on urinary symptoms, the baseline material consisted of 775 community-dwelling persons, of whom 366 were men and 409 were women.

The interviews were undertaken in the respondents' homes by female interviewers trained for the purpose. The cognitive ability of the interviewees to answer the questions was screened by a brief set of questions at the beginning of the questionnaire. In cases where the interviewee was not able to answer the questions himself or herself, a proxy interviewee was used. In our baseline material, proxies were used in 15 cases.

The vital status and the dates of death were provided by the national Population Register Center. There were no losses to mortality follow-up. During the 13-year follow-up, a total of 54.9% of the men and 48.4% of the women died.

Variables
Institutionalization.-- Institutionalization was defined as the date when the person was admitted to a nursing home or a hospital providing long-term care. Long-term care involved only cases where the person did not return to the ordinary home but either died in an institution or stayed in the institution until the end of the follow-up. The dates for admissions were derived from the computer files of the city of Tampere, which covered both public and private care units. However, as no computerized admission files were available for the time before 1994, these dates were manually extracted from the archives of all the institutions providing long-term care, including nursing homes and health center hospitals in the city of Tampere.

Urge incontinence.-- To define urge incontinence, the following question was asked: "Do you ever have trouble getting to the lavatory in time—yes or no?" In the case of a positive response, the following question was asked: "Do you have urinary leakage, either in the daytime or during the nights—never, rarely, frequently?" Urge incontinence was defined as having trouble getting to the lavatory in time with urinary leakage. The frequency of urine loss was not taken into account in the definition of incontinence.

Other health and social indicators.-- Living arrangements were categorized as living alone or living with somebody regardless of family relationship.

Chronic diseases were categorized as neurological, cardiovascular, musculoskeletal, or other chronic diseases. The group of other chronic diseases consisted of endocrine, gastrointestinal, infectious, respiratory, hematological, and mental disorders, and cancers. Only few respondents reported urogenital diseases, and since urge incontinence was used as an independent variable, we excluded these from the analyses.

ADL disability was defined as having difficulties in at least one of the following ADL tasks: walking between rooms, using the lavatory, washing oneself and taking a bath, dressing and undressing, getting in and out of bed, and eating.

Depressive symptoms were defined as at least one of the following symptoms during the last 2 weeks prior to the interview: difficulties in getting to sleep, unwillingness to do things or lack of energy, tiredness or feeling of faintness, nervous tension or nervousness, irritability or bursts of anger, and low spirits or depression.

Analyses
Cross-tabulations were used to describe the baseline distributions of the health and social indicators according to continence status and institutionalization during the 13-year follow-up in men and women at baseline. In the cross-tabulations, age was categorized into 3 classes: 60–69 years, 70–79 years, and 80 years and older. Depressive symptoms were also categorized into 3 classes: no symptoms, 1–3 symptoms, and 4–6 symptoms. Differences in the distributions were compared using chi-square statistics.

During follow-up, time was assessed as person-years, and the dates of admission to long-term institutional care were taken as the events. Time was counted up to the date of death for those who died at home and until the end of the follow-up period for those who survived living at home.

Cox proportional hazards models with relative risks (RR) and 95% confidence intervals (CI) were used to examine the age-adjusted association of urge incontinence and other health and social indicators with institutionalization. In the final multivariate analysis, all the indicators were simultaneously introduced into the model to detect the independent predictors of institutionalization. The analyses were conducted separately for men and women.

	Results

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The crude prevalence rates for urge incontinence in men and women were 5.2% and 14.7%, respectively. During the 13-year follow-up, 13.1% of men and 25.7% of women moved into an institution. Of the men, 49.8%, and of the women, 36.5%, died before being institutionalized.

Distribution of Health and Social Indicators According to Continence Status
The distributions of health and social indicators according to continence status in men and women at baseline are presented in Table 1. Cardiovascular diseases and ADL disability were significantly more frequent among men and women with urge incontinence, compared with men and women without the symptom. Women with urge incontinence reported significantly more musculoskeletal diseases and depressive symptoms than women without incontinence, while neurological diseases were significantly more common among men with than without incontinence.

Association of Urge Incontinence and Other Health and Social Indicators With Institutionalization
The age-adjusted and multivariate associations of urge incontinence and other health and social indicators with institutionalization (RR and 95% CI) are presented in Table 3.

In the multivariate analyses, where all the possible predictors were introduced simultaneously, age significantly predicted institutionalization in both men and women (RR 1.15, 95% CI 1.10–1.19, and RR 1.15, 95% CI 1.12–1.19, respectively). Urge incontinence remained a strongly significant predictor for institutionalization in men (RR 3.07; 95% CI 1.24–7.59). In addition, depressive symptoms still showed some predictive power (RR 1.22; 95% CI 1.0–1.49). In women, in addition to age, living alone was the only independent predictor in the multivariate analysis (RR 2.02; 95% CI 1.27–3.21).

	Discussion

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The most important finding in the present study was that urge incontinence in men predicted institutionalization independent of age, living arrangements, neurological, cardiovascular, and other chronic diseases, ADL disability, and depressive symptoms. In women, there was no association between urge incontinence and institutionalization. In the final multivariate model, living alone remained a significant predictor of institutionalization in women, and depressive symptoms showed some significant predictive power in men.

The assets of the study were a representative population sample with high enough response rate, a long follow-up period, an opportunity to examine the two genders separately, and the availability of several health and social indicators to be examined as possible predictors for institutionalization. Moreover, the specific strength of the study was that we were able to obtain exact dates not only for death but also for admissions to long-term institutional care.

The limitations of the study are those common to most other studies based on self-reported data. Similar to most of the epidemiological surveys on urinary incontinence, there was no clinical or urodynamic confirmation of the diagnosis (23,24). On the other hand, the currently revised standardization of definitions for lower urinary tract dysfunction by the International Continence Society emphasizes lower urinary tract symptoms as subjective indicators of a disease or condition as perceived by the patient (25). However, factors affecting an older person's subjective experience of the symptoms and willingness to report them, for example, due to embarrassment, may have affected the data (26). We believe that the reliability of our data on incontinence is satisfactory, the possible bias being more likely underreporting than overreporting.

Another limitation was that, in spite of using proxies in cases with obvious cognitive difficulties and defining neurological diseases as a disease group of its own, no questions more specifically assessing cognitive impairment and dementia were used. This was simply due to the fact that the original design of the survey in 1979 did not include any measures for cognitive domain. Using self-report in the assessment of comorbidity may also have affected the accuracy of the data. However, self-report is commonly used, especially in large-scale epidemiological surveys, as a measure for various disease conditions, bearing in mind its limitations (27).

Quite expectedly, ADL disability significantly predicted institutionalization during the 13-year follow-up both in men and women when adjusted for age. That cardiovascular diseases had predictive value in women but not in men may be explained by the gender difference in the cardiovascular mortality between men and women. It has been suggested, for example, that older women with heart failure live longer compared with men (28). Of the other separate disease groups, neurological diseases in men and musculoskeletal diseases in women approached statistical significance, while the group of other chronic diseases was a significant predictor both in men and women. The latter group consisted of chronic and potentially disabling diseases such as respiratory diseases, mental diseases, and cancers (29).

An association was noted between living alone and institutionalization in women but not in men. The reason for this could be that fewer older men, compared with older women, generally live alone. Furthermore, older women, more likely than older men, are known to be single. Living alone, especially for women, may thus be an indicator of inadequate social support provided by kin that is required to compensate the need of care when becoming disabled over time. A recent study suggested that, among older women in need of help, those who lived alone had a higher risk of sustained need for help over a 5-year period compared with women who lived with others (30). This was not seen in poorly functioning men. Moreover, it has been suggested that even though women are generally regarded as major caregivers, male spouses may also have a much more significant role in the task of caregiving than is commonly believed (8).

Previously, depressive symptoms have been found to predict use of services among elderly medical inpatients (31) and admission to long-term institutional care in a random older population (3). No differentiation was made between the two genders. In the present study, the association of depressive symptoms and institutionalization approached statistical significance in women, while the age-adjusted predictive association of depressive symptoms in men showed some predictive power even in the final multivariate model. However, as the symptoms we asked about do not constitute a validated measure, the results should be interpreted with caution.

The key finding in our study that urge incontinence predicted institutionalization in men but not in women is consistent with the study by Thom and colleagues, who noted that medically recognized urinary incontinence predicted nursing home admission more markedly in men than in women (20). The finding may imply that urge incontinence is a marker of later and more generalized disability in men, while in women it may occur earlier and without functional impairment. It is worth noting that our definition for ADL disability was a relatively rough one and did not separate more severe disabilities from milder ones. However, the fact that urge incontinence predicted institutionalization in men even independently of ADL disability suggests that there could be other potential explanations for the gender difference observed here. It has been pointed out that incontinence is not an inevitable consequence of cognitive or functional decline (32,33). A common cause of urge incontinence in older men is benign prostatic enlargement due to hyperplasia. This is unlikely to cause physical disability, although it may seriously affect the quality of life (34). Interestingly, incontinent men required significantly more daily time and effort from the caregiver compared with that required for incontinent women (35). The authors suggested that this could be explained by sociocultural differences and differences in the types of incontinence between the genders.

Finally, our findings should be generalized to other populations with caution. The decision to institutionalize a person depends on such local factors as the availability of not only long-term care facilities but also of community-based services. Furthermore, there could be differences between rural and urban communities. For example, rural communities in contrast to urban communities in one U.S. locality were more likely to institutionalize a person suffering from incontinence presumably due to lack of community-based services in those regions (36). Moreover, there may be cultural differences in dealing with various disabilities such as urinary incontinence at the family and societal level.

Conclusion
In addition to age, urge incontinence and depressive symptoms in men and living alone in women are independent predictors of institutionalization. The overall prognostic significance of urge incontinence seems to be greater in older men than in women. An independent association between urgency and urge incontinence and mortality in men but not in women was recently suggested when using the same kind of definitions (37). Urge incontinence may be a marker of advanced disability in men, but differences in etiological pathways and psychosocial factors may also explain in part the gender difference. However, further studies on the subject with standardized definitions for urinary symptoms and possible confounders are needed. Nevertheless, interventions aiming at promoting continence and coping with the problem should be encouraged both in clinical practice and whenever community-based services and supportive systems for caregivers are being designed.

	Acknowledgments

 
This work was financially supported by the Medical Research Fund of Tampere University Hospital, the Academy of Finland, and the Uulo Arhio Foundation.

Address correspondence to Maria Nuotio, MD, Vaasa City Hospital, Sepankylantie 14-16, Vaasa FIN-65100, Finland. E-mail: maria.nuotio{at}netikka.fi

Received October 7, 2002

Accepted January 23, 2003

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