Use of this content is subject to the Terms and ConditionsNocturnal Enuresis in Community-Dwelling Older AdultsJournal of the American Geriatrics Society - Volume 44, Issue 2 (February 1996)-Copyright 1996American Geriatrics Society139CLINICAL INVESTIGATIONNocturnal Enuresis in Community-Dwelling Older AdultsKathryn L. Burgio PhDJulie L. Locher MADiane G. Ives MPHJ. Michael Hardin PhDAnne B. Newman MD, MPHLewis H. Kuller MD, DrPHUniversity of Alabama at Birmingham School of Medicine and Center for Aging,Birmingham, Alabama; and the University of PittsburghGraduate School of Public HealthDivision of Geriatric Medicine,Pittsburgh, Pennsylvania.OBJECTIVE: To investigate the prevalence and characteristics of nocturnal enuresis in community-dwelling older adults andto identify potential predisposing variables.DESIGN: Interview survey.SETTING: Five rural counties in northwestern Pennsylvania.PARTICIPANTS: Subjects were 3884 community-dwelling older adults aged 65 to 79 years who volunteered for a healthpromotion demonstration.MEASUREMENTS: The dependent variable was self-reported accidental loss of urine during sleep. Independent variablesincluded demographic variables, self-reported disease history and symptomatology, and standardized screening instrumentsfor depression (CES-D), dementia (MMSE), and functional status (ADLs).MAIN RESULTS: Prevalence of nocturnal enuresis was 2.1%, and was significantly higher among women (2.9%) comparedwith men (1.0%; P < .0001). Compared with subjects with daytime incontinence only, those with nocturnal enuresis reportedgreater severity and impact of incontinence on several parameters. Enuretics were more likely to have received treatment;treatment outcome, however, was significantly less successful. In univariate analyses, enuresis was significantly associated withsymptoms of congestive heart failure (CHF), impairment in activities of daily living, depression, and use of sleep medicationsat least once per week. In stepwise logistic regression modeling, two symptoms of congestive heart failure and regular use ofsleep medication entered the model.CONCLUSIONS: Nocturnal enuresis appears to be uncommon among older adults, but it may be associated with poorertherapeutic outcomes compared with the more common forms of daytime incontinence. The findings are consistent with thehypothesis that daytime fluid accumulation followed at night by mobilization of excess fluid is a contributor to enuresis inolder adults.This study was supported by HCFA cooperative agreement #95-C-99159/3 and by Research Career Development AwardMD Consult - Nocturnal Enuresis in Community-Dwelling Older Adults ... http://www.mdconsult.com.ezproxy.med.nyu.edu/das/article/body/3950...1 of 9 1/11/2013 9:28 AMK04-AG00431 from the NIA.Address correspondence to Kathryn L. Burgio, PhD, Geriatric Medicine Clinic, 920 19th St. South, Birmingham, AL, 35294-2100.Nocturnal enuresis is fairly common in childhood, affecting approximately 30% of 5-year-old [1]and 10% of 6-year-old children. [2]Ordinarily, it resolves spontaneously so that only 4 to 5% of 12-year-old children continue to wet the bed. [1][3][4]In adulthood,enuresis is much less common, with prevalence rates ranging from 1 to 3.7%. [2][5][6][7]Little is known about the prevalence of nocturnal enuresis in older adults. Data from a single study of more than 1000 older people (75years of age or older) living at home indicated that 2.4% had nocturnal enuresis and that it was more common among women (2.8%)than men (1.4%). [7]The causes of primary childhood enuresis have been investigated extensively, [8]but little has been done to elucidate the mechanismsof nocturnal enuresis in older adults. One hypothesis is that enuresis results from bladder instability or reduced bladder capacity.Another hypothesis suggests that enuresis is caused by disturbance of the circadian rhythm of urine excretion. It is known that normaladults excrete twice as much urine during the day as they do at night. [9][10]It has been suggested that this pattern is reversed forenuretic children, [9][11][12]and there is some evidence that it is reversed in older people as well. [13][14]If nighttime urineproduction is truly increased in older adults, they could then be predisposed to nocturia, which increases with age, [15]as well as tonocturnal enuresis.In studies of children, which include a small number of adult subjects, evidence suggests that the nocturnal polyuria in enuretics mayresult from abnormally low levels of arginine vasopressin (AVP) at night. [12][16][17]This provides the rationale for treating enuresiswith the synthetic vasopressin analogue desmopressin (DDAVP), which has yielded successful results in children. [11][18][19][20]Thedata that do exist on AVP secretion in older adults indicate that the normal diurnal rhythm with increased AVP at night is absent inhealthy, older adults and that they displayed increased nocturnal diuresis. [21][22]DDAVP has been shown to reduce nighttime urinevolumes in older patients and has been used successfully to treat nocturia. [23][24]An alternative mechanism proposed to explain increased urine production at night attributes the phenomenon to edema. Fluid mayaccumulate with upright position during the day and be excreted during the night as a result of the recumbent position. Such amechanism presumably would mean that patients with edema, such as that related to congestive heart failure (CHF), would be moresusceptible to nocturnal enuresis. One study tested the role of posture on water balance in older adults. [25]Bedrest resulted in similaramounts of urine output during the day and night. Sitting upright during the day, however, produced a mean excess of140321 mL of urine output at night compared with daytime. Consistent with this concept, research on nursing home residents has shownthat total volume of urine output is generally greater at night, with a mean 54% of total urine excreted at night. [26]The oppositepattern of more urine output during the day was associated with use of diuretics.The purpose of the present study was to investigate the prevalence and characteristics of nocturnal enuresis in community-dwellingolder adults and to identify potential predisposing variables. Nocturnal enuresis is examined in relation to demographic variables,functional status, cognitive function, medical conditions, sleep habits and medications, and other variables that might clarify thefactors that contribute to incontinence during sleep.METHODSSubjectsSubjects were 3870 participants in the Rural Health Promotion Project (RHPP), a community-based preventive health study ofnoninstitutionalized older adults (aged 65-79) living in five rural counties of Western Pennsylvania. Potential subjects were identifiedusing Medicare entitlement data from Health Care Financing Administration tapes. Recruitment for the RHPP included mass mailings,publicity, and telephone contact and was targeted at Medicare Part B beneficiaries 65 to 79 years of age. [27]In addition to the agerequirement, eligibility criteria included Medicare Part B participation and county residence. Subjects also had to benoninstitutionalized, ambulatory, and without a diagnosis of life-threatening cancer within 5 years preceding the study.MeasuresEligible participants completed an in-person Health Risk Appraisal (HRA) interview administered by a local interviewer.MD Consult - Nocturnal Enuresis in Community-Dwelling Older Adults ... http://www.mdconsult.com.ezproxy.med.nyu.edu/das/article/body/3950...2 of 9 1/11/2013 9:28 AMOne section of the HRA focused on urinary incontinence. Participants were first asked if they had experienced any involuntary loss ofurine in the past year. These individuals were then questioned about the frequency, volume, and circumstances of incontinent episodes,which information was used to categorize subjects according to type. A positive response to loss of urine during sleep was consideredevidence of nocturnal enuresis. Those who stated that they leaked with coughing, sneezing, or other physical exertion were consideredto have stress incontinence. Those who reported that they leaked in the presence of a strong urge to void were categorized as havingurge incontinence.Subjects were also asked how much money was spent on protection and whether they considered incontinence to be a problem. Impactof incontinence was assessed using 10-point scales to measure how much incontinence restricted their activities and how much itaffected how they feel. Finally, they were asked to report whether they had told their physician about their loss of urine, whether theyhad received treatment, and the effect of treatment on their incontinence.The 1.5-hour HRA interview also included questions pertaining to demographics, self-reported medical history and diseasesymptomatology, use of alcohol, social support, and sleep patterns. The demographic variables included were gender, age, race,marital status, (married vs not married), employment status (employed vs not employed), and living arrangements (alone vs withothers). Medical history included history of or treatment of hypertension, stroke, diabetes, or kidney problems. Self-reported diseasesymptomatology included the following symptoms of CHF: the need to sleep on two or more pillows to breathe, shortness of breath atnight, being awakened at night by trouble breathing, shortness of breath without pillows, swelling of feet, and shortness of breathwhen hurrying. Female subjects were also queried about parity (number of children born alive) and current use of estrogen. Use ofalcohol was assessed by questions about the frequency and quantity of consumption. One dimension of medical care utilization wasdefined by the frequency of physical examinations. Social support was measured using the Lubben Social Network Scale and subjects'ratings of satisfaction with the quality and quantity of social contacts (not at all, somewhat, very).Sleep was assessed by subjects' ratings of sleep quality (very good to very bad) and the number of hours of actual sleep they get atnight. They were asked about the frequency with which they used sleep medications, but the type of medication was not noted.Standardized screening instruments were administered for depression (CES-D), [28]dementia (MMSE), [29]and functional status(ADLS). [30]Measurements of height and weight were converted to body mass index (kg/m.2 ).AnalysesFor purposes of analysis, whether the subject had nocturnal enuresis or daytime incontinence alone is the dependent variable, and theother variables derived from the HRA interview are the independent variables. Outcome-specific univariate descriptives werecalculated for each of the independent factors to assess whether differences existed between the two groups. These differences weretested using the t test for continuous variables and the chi-square test for categorical variables. Subsequently, multicollinearity amongthe variables was examined using standard procedures, and highly collinear variables were deleted. Then stepwise logistic regressionwas used to select factors that were independent predictors of enuresis. The critical value to enter and remove variables for theprocedure was 0.15.RESULTSThe Health Risk Appraisal interview was administered to 3884 participants (1679 men and 2205 women). Of the 1104 (28.4%) whoreported incontinence in the previous year, 14 did not provide information about whether incontinence occurred during sleep, leaving1090 incontinent participants (269 men and 821 women) who provided complete answers.PrevalenceEighty (7.3%) incontinent subjects reported that urine loss occurred during sleep. Prevalence in the total sample was 2.1% (n =80, 16men and 64 women).The prevalence of nocturnal enuresis for the total sample was higher in women (2.9%) than in men (1.0%; P