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To evaluate tamsulosin (α-blocker therapy) for male overactive bladder (OAB) and to examine if indicators of concomitant benign prostatic hyperplasia are associated with OAB symptom improvement.This was a planned, exploratory analysis of a 4-week, α-blocker (tamsulosin 0.4 mg) run-in phase of the Male Overactive Bladder Trial in Veterans (MOTIVE). Participants with urinary urgency and urinary frequency (8 voids/24 hours) completed bladder diaries, answered symptom questionnaires (AUA-7 SI), and had post-void residual and noninvasive uroflowmetry measurement.A total of 116 male Veterans aged 42-88 years with OAB participated. There were statistically significant reductions in voiding frequency (11.310.0 voids/24 hours, P.0001), urgency scores (mean 2.5-2.2 points, P.0001), and nightly nocturia (2.11.8, P.001). Only baseline AUA-7 SI total and voiding subscale categories (mild, moderate, severe) were associated with significant reduction in AUA-7 SI total score. For continuous variables, only AUA-7 SI baseline total score was associated with AUA-7 SI storage symptom changes. No other baseline measures were associated with changes in urgency, frequency, or nocturia.Initiation of short course tamsulosin therapy in men was associated with statistical reduction in OAB symptoms. Baseline post-void residual, uroflow rate, and the voiding symptom subscore of the AUA-7 SI were not predictive of OAB symptom improvement with tamsulosin. These findings merits further exploration.

Although nocturia is associated with various comorbidities, its impact on falls and fractures remains unclear. We performed a systematic review and meta-analysis to evaluate the association between nocturia and falls and fractures as a prognostic and as a causal risk factor.We searched PubMed®, Scopus®, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and abstracts of major urological meetings up to December 31, 2018. We conducted random effects meta-analyses of adjusted relative risks of falls and fractures. We applied the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate the quality of evidence for nocturia as a prognostic and causal factor of falls and fractures.Among 5,230 potential reports 9 observational longitudinal studies provided data on the association between nocturia and falls or fractures (1 for both, 4 for falls, 4 for fractures). Pooled estimates demonstrated a risk ratio of 1.20 (95% CI 1.05-1.37, INocturia is probably associated with an approximately 1.2-fold increased risk of falls and possibly an approximately 1.3-fold increased risk of fractures.

Purpose The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) program is a quality improvement initiative that combines education, clinical decision support (ie, geriatric pharmacy order sets), and in-person academic detailing coupled with audit and feedback in an effort to improve appropriate prescribing to older veterans discharged from the emergency department. Although the EQUIPPED program is effective at reducing the prescribing of potentially inappropriate medications, the reliance on in-person academic detailing may be a limitation for broader dissemination. The EQUIPPED dashboard is a passive yet continuous audit and feedback mechanism developed to potentially replace the in-person academic detailing of the traditional EQUIPPED program. We describe the development process of the EQUIPPED dashboard and the key audit and feedback components found within. Methods The Veterans Affairs (VA) Corporate Data Warehouse (CDW) serves as the underlying data source for the EQUIPPED dashboard. SQL Server Integration Services was used to build the backend data architecture. Data were isolated from the CDW for reporting purposes using an extract, load, transform (ELT) approach. The team used SQL Server Reporting Services to produce the user interface and add interactive functionality. The team used an agile development approach when designing the user interface, engaging end users at 2 VA EQUIPPED implementation sites by providing printed screenshots of a beta version of the dashboard. Findings The EQUIPPED dashboard ELT process executes nightly to provide dashboard end users with a near real-time data experience and the potential for daily audit and feedback. The following dashboard components were identified as necessary for the EQUIPPED dashboard to be a suitable audit and feedback tool: key performance indicators, peer-to-peer benchmarking, individual patient or encounter drill down, educational decision support, and longitudinal performance tracking. Implications To our knowledge, the EQUIPPED dashboard is the first information display of its kind with built-in audit and feedback that has been developed for VA emergency department practitioners as the primary end users. Further investigation is warranted to determine whether the EQUIPPED dashboard is a suitable alternative to in-person academic detailing. The EQUIPPED dashboard will be leveraged in a formal implementation trial that will entail the randomization of multiple VA sites to either (1) traditional EQUIPPED with in-person academic detailing coupled with audit and feedback or (2) EQUIPPED with passive audit and feedback delivered through the EQUIPPED dashboard without in-person prescribing outreach.

Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. We describe prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme.EQUIPPED was adapted from a model developed in the Veterans Health Administration (VA) and sequentially implemented in one academic health system per year over a 3-year period. The monthly proportion of PIMs, as defined by the 2015 American Geriatrics Beers Criteria, of all medications prescribed to adults aged 65 years and older at discharge was assessed for 6 months preimplementation until 12 months postimplementation using a generalised linear time series model with a Poisson distribution.The EQUIPPED programme was translated from the VA health system and its electronic medical record into three health systems each using a version of the Epic electronic medical record. Adaptation occurred through local modification of order sets and in the generation and delivery of provider prescribing reports by local champions. Baseline monthly PIM proportions 6 months prior to implementation at the three sites were 5.6% (95% CI 5.0% to 6.3%), 5.8% (95% CI 5.0% to 6.6%) and 7.3% (95% CI 6.4% to 9.2%), respectively. Evaluation of monthly prescribing including the twelve months post-EQUIPPED implementation demonstrated significant reduction in PIMs at one of the three sites. In exploratory analyses, the proportion of benzodiazepine prescriptions decreased across all sites from approximately 17% of PIMs at baseline to 9.5%–12% postimplementation, although not all reached statistical significance.EQUIPPED is feasible to implement outside the VA system. While the impact of the EQUIPPED model may vary across different health systems, results from this initial translation suggest significant reduction in specific high-risk drug classes may be an appropriate target for improvement at sites with relatively low baseline PIM prescribing rates.

Symptom or palliative management for wound care has commonly been reported in the literature as being focused on end-of-life care with less emphasis on being an effective supportive option for any patient with a wound in whom symptom management is indicated. This case report describes a frail older patient with a hard-to-heal pressure injury and multiple comorbidities to highlight palliative symptom management as a viable option to enhance patient comfort. Wound care providers may consider a palliative approach for hard-to-heal wound management that incorporates the whole patient, family and/or caregiver when faced with management of a frail older adult with a hard-to-heal wound to enhance the relief of suffering and improve quality of life. All procedures were performed in compliance with relevant laws and institutional guidelines and the appropriate institutional committee has approved them. Declaration of interest: The authors have no conflicts of interest to declare.

Aim Determine the efficacy of behavioral therapy for urinary symptoms in Parkinson's disease. Methods Randomized trial of behavioral therapy compared with control condition among adults (aged 54-85 years, 74% male, 10% Black/ 83% White) with Parkinson's and greater than or equal to 4 incontinence episodes weekly. Behavioral therapy included pelvic floor muscle exercises, bladder training, fluid and constipation management. Both groups completed bladder diary self-monitoring. Outcomes included diary-derived incontinence and ICIQ-overactive bladder (OAB) score (range, 0-16) with bother and quality of life questionnaires (higher scores = worse outcomes). Results Fifty-three participants randomized and 47 reported 8-week outcomes including 26 behavioral therapy and 21 control. Behavioral vs control participants were similar with respect to age (71.0 ± 6.1 vs 69.7 ± 8.2 years), sex (70% vs 78% male), motor score, cognition, mean weekly incontinence episodes (13.9 ± 9.6 vs 15.1 ± 11.1) and OAB symptoms (8.9 ± 2.4 vs 8.3 ± 2.2). Weekly incontinence reduction was similar between behavioral (-6.2 ± 8.7) and control participants (-6.5 ± 13.8) (P = 0.89). After multiple imputation analysis, behavioral therapy participants reported statistically similar reduction in OAB symptoms compared to control (-3.1 ± 2.8 vs -1.9 ± 2.2, P = 0.19); however quality of life (-22.6 ± 19.1 vs -7.0 ± 18.4, P = 0.048) and bother (-12.6 ± 17.2 vs - 6.7 ± 8.8, P = 0.037) improved significantly more with behavioral therapy. Conclusion Self-monitoring resulted in fewer urinary symptoms; however, only multicomponent behavioral therapy was associated with reduced bother and improved quality of life. Providers should consider behavioral therapy as initial treatment for urinary symptoms in Parkinson's disease.

This review focuses on updates in the management of urinary incontinence occurring in older adult populations living with conditions frequently managed by physical medicine and rehabilitation specialists. Urinary incontinence is common among older adults who live with neurologic diseases, such as stroke, Parkinson’s disease, multiple sclerosis, and traumatic brain injury, and may be cared for in outpatient and acute rehabilitation facilities. While the evidence is growing regarding treatment strategies specific to patients with neurogenic bladder, behavioral treatment approaches may be a viable first option depending on cognitive status and mobility. Drug therapy choices should consider mechanism of action and formulation to minimize the potential for adverse effects. Minimally invasive strategies provided by continence specialists are available for refractory symptoms. Evidence suggests a multidisciplinary approach incorporating multicomponent treatment strategies can improve common urinary symptoms among older adults in both outpatient and acute inpatient rehabilitation settings of care.

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

BACKGROUND: Observational studies among older women have associated vitamin D insufficiency with greater prevalence and incidence of urinary incontinence than older women with adequate vitamin D status. Less is known about the effect of vitamin D supplementation on reducing incontinence. OBJECTIVE: To evaluate the effects of vitamin D supplementation for reducing urinary incontinence frequency in older women. STUDY DESIGN: We conducted an ancillary study of women aged 55 years and older in the Vitamin D and Omega-3 Trial (VITAL), a randomized trial with a 2 × 2 factorial design. Recruitment was from 2011 to 2014, across 50 US states, and follow-up ended January 2018. Randomized treatments in the parent study included: 1) vitamin D(3) (cholecalciferol) at a dose of 2000 IU/day, 2) marine omega-3 fatty acids at a dose of 1 g/day, or matching placebo. For this ancillary study, we analyzed women according to their randomization to vitamin D supplementation or placebo, regardless of treatment with omega-3 fatty acid supplementation. Validated urinary incontinence frequency questions were added in year 2 and repeated in year 5 at the trial close. Pre-specified ancillary outcomes included the prevalence of urinary incontinence at year 2 and at year 5, along with incident incontinence and progression of incontinence (from lower to higher frequency) from year 2 to year 5. Pre-planned subgroup analyses examined these outcomes in women with low pre-randomization serum levels of vitamin D [25(OH)D

PURPOSE: The goal of this study was to determine if the US adult population with nocturia (waking from sleep at night to void) can easily take medications (desmopressin acetate) approved by the US Food and Drug Administration for nocturia. The study examined: (1) the prevalence of comorbid conditions, laboratory abnormalities, and concomitant medications that increase risk of desmopressin use; and (2) whether these factors are associated with age or nocturia frequency. METHODS: Using a cross-sectional analysis of four US National Health and Nutrition Examination Survey (NHANES) waves (2005–2012), a total of 4111 participants aged ≥50 years who reported ≥2 nightly episodes of nocturia were identified. The main outcome was frequency of contraindications and drug interactions as described in US Food and Drug Administration–approved prescribing information. These prescribing concerns were matched to examination findings, medical conditions, concomitant medications, and laboratory results of NHANES participants. The associations between prescribing concerns and nocturia severity and age groups were examined. FINDINGS: The mean participant age was 65.7 years (95% CI, 65.3–66.1), and 45.5% were male. Desmopressin prescribing concerns were present in 80.5% (95% CI, 78.0–82.9) of those ≥50 years of age with nocturia; 50.0% (95% CI, 47.0–53.0) had contraindications, and 41.6% (95% CI, 39.3–44.0) took a concomitant drug that could increase risk of low serum sodium. Desmopressin contraindications were higher with older age (P < 0.001) and present in 73.2% (95% CI, 69.3–77.1) of those ≥80 years of age. IMPLICATIONS: Using NHANES data, this study showed that older US adults with nocturia have a high prevalence of medical conditions, concomitant medications, and baseline laboratory abnormalities that likely increase the risk of potentially severe adverse side effects from desmopressin use. A medication designed and approved for a clinical symptom that is most common in older adults could not be taken by most of the older adults with the symptom.

Summary Background Lower urinary tract symptoms (LUTS) are common in children and adolescents. Non-invasive tests evaluating bladder function are generally preferred over invasive tests, yet few studies have explored the range of normative values for these tests in healthy, asymptomatic children. Objective To define normative reference ranges for non-invasive tests of bladder function in healthy, asymptomatic girls and adolescents. Study design A comprehensive search strategy was performed in seven electronic databases through October 2019. English-language studies reporting data on voiding frequency, voided and postvoid residual volumes (PVR) and uroflowmetry results in healthy, asymptomatic girls (mean age ≥ 5 years) were included. Two independent reviewers performed study review, data extraction, and quality assessment. Overall mean estimates and 95% confidence intervals for each bladder function parameter were calculated using random effects models, and 95% normative reference values were estimated. Results Ten studies met eligibility criteria for the meta-analysis (n = 2143 girls, age range: 3–18). Mean estimates of maximum voided volume and PVR were 233.4 ml (95% CI 204.3–262.6; n = 1 study) and 8.6 ml (95% CI 4.8–12.4; n = 2 studies) respectively. Pooled mean estimates for uroflowmetry parameters were: 21.5 ml/s (95% CI 20.5–2.5) for maximum flow rate (n = 6 studies), 12.5 ml/s (95% CI 11.2–13.8) for mean flow rate (n = 6 studies), 6.8 s (95% CI 4.4–9.3) for time to maximum flow (n = 3 studies), 15.7 s (95% CI 13.0–18.5) for flow time (n = 3 studies), and 198.7 ml (95% CI 154.2–234.2) for voided volume (n = 9 studies). No studies reported estimates of voiding frequency. Between-study heterogeneity was high (89.0–99.6%). Conclusions Although we were able to calculate pooled mean estimates for several parameters, the small number of included studies and the wide age ranges of participants preclude generalization of reference values to all healthy girls. Further research is needed to determine normative reference values within specific age groups.

IMPORTANCE: First-line behavioral and drug therapies for overactive bladder (OAB) symptoms in men are effective but not usually curative. OBJECTIVE: To determine whether combining behavioral and drug therapies improves outcomes compared with each therapy alone for OAB in men and to compare 3 sequences for implementing combined therapy. DESIGN, SETTING, AND PARTICIPANTS: In this 3-site, 2-stage, 3-arm randomized clinical trial, participants were randomized to 6 weeks of behavioral therapy alone, drug therapy alone, or combined therapy followed by step-up to 6 weeks of combined therapy for all groups. Participants were recruited from 3 outpatient clinics and included community-dwelling men 40 years or older with urinary urgency and 9 or more voids per 24 hours. Data were collected from July 2010 to July 2015 and analyzed from April 2016 to September 2019. INTERVENTIONS: Behavioral therapy consisted of pelvic floor muscle training with urge suppression strategies and delayed voiding. Drug therapy included an antimuscarinic (sustained-release tolterodine, 4 mg) plus an α-blocker (tamsulosin, 0.4 mg). MAIN OUTCOMES AND MEASURES: Seven-day bladder diaries completed before and after each 6-week treatment stage were used to calculate reduction in frequency of urination (primary outcome) and other symptoms (ie, urgency, urgency incontinence, and nocturia). Other secondary outcomes included validated patient global ratings of improvement and satisfaction, Overactive Bladder Questionnaire score, and International Prostate Symptom Score. RESULTS: Of the 204 included men, 133 (65.2%) were white, and the mean (SD) age was 64.1 (11.1) years. A total of 21 men discontinued treatment and 183 completed treatment. Mean (SD) voids per 24 hours decreased significantly in all 3 groups from baseline to 6-week follow-up (behavioral therapy: 11.7 [2.4] vs 8.8 [2.1]; change, 2.9 [2.4]; percentage change, 24.7%; P

Objective To determine if vitamin D intake is associated with reduced progression of urgency urinary incontinence (UI) in women. Methods We used the Nurses’ Health Study (NHS) I and NHSII cohorts to evaluate the association of vitamin D intake with progression of urgency UI and mixed UI, from mild-moderate to severe symptoms, from 2004 to 2012 (NHS) and 2005-2013 (NHSII). Intake of vitamin D at study baseline was categorized and updated at the start of each 2-4 year follow-up period. Multivariable-adjusted relative risks (RRs) and 95% confidence intervals (95% CI) of progression to severe UI were estimated using Cox proportional hazard models. Results At baseline, of the 20,560 older women (age range 58-73 years) in NHS I with mild/moderate urgency or mixed UI, 21% reported oral vitamin D intake of at least 800 IU per day. Among 12,573 middle-aged women (age range 42-59) in NHS II with mild/moderate urgency or mixed UI, 17% reported oral vitamin D intake of at least 800 IU daily. From 2004 to 2012, 4853 incident cases of urgency/mixed UI progression were identified among older women. From 2005 to 2013, 1378 incident cases of urgency/mixed UI progression were identified among middle-aged women. After multivariable adjustment, no significant associations between vitamin D intake and incidence of urgency/mixed UI progression were observed in either cohort (RR = 1.10, 95% CI 0.99-1.23 in older women, RR = 0.88, 95% CI 0.71, 1.10 in middle-aged women). Conclusion Despite interest in vitamin D as a low-cost strategy to prevent or reduce UI, our findings indicate oral vitamin D may not reduce urgency/mixed UI progression.

OBJECTIVES To estimate the efficacy of vitamin D supplementation to reduce urgency urinary incontinence (UUI) episodes. DESIGN Pilot, two-arm, randomized trial conducted from 2013 to 2017. Interventions were 12 weeks of weekly oral 50,000 IU vitamin D3 or placebo. SETTING Academic, university-based outpatient clinic. PARTICIPANTS Community-dwelling postmenopausal women, 50 years or older, with at least three UUI episodes on 7-day bladder diary and serum vitamin 25-hydroxyvitamin D (25[OH]D) of 30 ng/mL or less. MEASUREMENTS The primary efficacy estimate was the percentage change in UUI episodes. Secondary estimates included changes in other lower urinary tract symptoms, along with exploratory subgroup analysis by race/ethnicity and obesity. RESULTS We randomized 56 women (aged 50-84 years; mean = 60.5 ± 8.2 years), 28 to vitamin D and 28 to placebo; 51 completed treatments. Mean serum 25(OH)D at baseline (21.2 ± 5.2 and 18.2 ± 5.6, P = .30) improved to 57.9 ± 16.3 ng/mL with vitamin D3 and 21.9 ± 8.2 ng/mL with placebo (P < .001). UUI episodes per 24-hour day decreased by 43.0% with vitamin D3 compared to 27.6% with placebo (P = .22). Among black women (n = 33), UUI episodes decreased by 63.2% with vitamin D3 compared to 22.9% with placebo (P = .03). Among obese women, UUI episodes decreased by 54.1% with vitamin D compared to 32.7% with placebo (P = .29). For all women, changes in voiding frequency (P = .40), nocturia (P = .40), urgency (P = .90), incontinence severity (P = .81), and overactive bladder symptom severity (P = .47) were not different between arms. CONCLUSIONS Postmenopausal women with UUI and vitamin D insufficiency demonstrated a greater than 40% decrease in UUI episodes, which did not reach statistical significance compared to placebo, except in the subset of black women. The results of this pilot study support further investigation of vitamin D3 alone or in combination with other treatments for UUI, particularly for women in higher-risk subgroups. J Am Geriatr Soc 67:570-575, 2019.

Objective To identify patterns of prevalent chronic medical conditions among women with urinary incontinence (UI). Materials and methods We combined cross-sectional data from the 2005-2006 to 2011-2012 US National Health and Nutrition Examination Surveys, and identified 3 800 women with UI and data on 12 chronic conditions. Types of UI included stress UI (SUI), urgency UI (UUI), and mixed stress and urgency UI (MUI). We categorized UI as mild, moderate or severe using validated measures. We performed a two-step cluster analysis to identify patterns between clusters for UI type and severity. We explored associations between clusters by UI subtype and severity, controlling for age, education, race/ethnicity, parity, hysterectomy status and adiposity in weighted regression analyses. Results Eleven percent of women with UI had no chronic conditions. Among women with UI who had at least one additional condition, four distinct clusters were identified: (i) cardiovascular disease (CVD) risk-younger; (ii) asthma-predominant; (iii) CVD risk-older; and (iv) multiple chronic conditions (MCC). In comparison to women with UI and no chronic diseases, women in the CVD risk-younger (age 46.7 ± 15.8 years) cluster reported the highest rate of SUI and mild UI severity. In the asthma-predominant cluster (age 51.5 ± 10.2 years), women had more SUI and MUI and more moderate UI severity. Women in the CVD risk-older cluster (age 57.9 ± 13.4 years) had the highest rate of UUI, along with more severe UI. Women in the MCC cluster (age 61.0 ± 14.8 years) had the highest rates of MUI and the highest rate of moderate/severe UI. Conclusions Women with UI rarely have no additional chronic conditions. Four patterns of chronic conditions emerged with differences by UI type and severity. Identification of women with mild UI and modifiable conditions may inform future prevention efforts.

Background Mobile health (mHealth) apps using novel visual mapping assistive technology can allow users to develop personalized maps that aid people living with cognitive impairment in the recall of steps needed to independently complete activities of daily living (ADLs), such as bathing, toileting, and dressing. Objective This study aims to determine the feasibility and preliminary impact of an mHealth assistive technology app providing guidance to aid individuals living with cognitive impairment in the recall of steps to independently complete ADLs. Methods A total of 14 Veterans (mean age 65 SD 9.5 years; 14/14, 100% male; 10/14, 71.4% Black) and 8 non-Veterans (mean age 78, SD 10.3 years; 5/8, 62.5% male; 8/8, 100% Black) were recruited and enrolled from the Department of Veterans Affairs (VA) and non-VA cognitive care clinics. A visual mapping software program, MapHabit, was used to generate a series of personalized visual map templates focused on ADLs created within the MapHabit app. The visual maps were accessed through a tablet device. A 19-item exit questionnaire was administered to the participants to assess perceived improvement in their functional ability after using the MapHabit system for 3 months. Results A total of 13 (93%) VA clinic participants and 8 (100%) non-VA clinic participants completed the 3-month study. Baseline cognitive testing indicated impaired to significantly impaired cognitive function. After 3 months of using the MapHabit system, VA clinic participants reported perceived improvement in social engagement (P=.01) and performance of ADLs (P=.05) compared to the baseline, whereas non-VA clinic participants reported improvements in the performance of ADLs (P=.02), mood (P=.04), social engagement (P=.02), and memory (P=.02). All study participants reported they would recommend the MapHabit system to a colleague, and 85% (11/14) of VA and 100% (8/8) of non-VA clinic participants reported a willingness to participate in a future study. Conclusions Older VA and non-VA clinic participants with cognitive impairment were willing to use an mHealth app to assist with the completion of ADLs, and they reported positive preliminary effects. A larger study is warranted to assess the efficacy in the setting of a randomized controlled trial.

The American Geriatrics Society (AGS), with support from the National Institute on Aging (NIA) and other funders, held its ninth Bedside-to-Bench research conference, entitled “Urinary Incontinence in the Older Adult: A Translational Research Agenda for a Complex Geriatric Syndrome,” October 16 to 18, 2016, in Bethesda, Maryland. As part of a conference series addressing three common geriatric syndromes—delirium, sleep and circadian rhythm (SCR) disturbance, and urinary incontinence—the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these conditions. The conference provided a forum for discussing current epidemiology, basic science, clinical, and translational research on urinary incontinence in older adults; for identifying gaps in knowledge; and for the development of a research agenda to inform future investigative efforts. The conference also promoted networking involving emerging researchers and thought leaders in the field of incontinence, aging and other fields of research, as well as National Institutes of Health program personnel.

Objectives (1) To examine relationships between frequency of nocturia and self-reported sleep quality and objective sleep measures in older women, and (2) to estimate the amount of variation in sleep measures that is specifically attributable to frequency of nocturia. Design and setting Secondary, cross sectional analysis of the multicenter prospective cohort Study of Osteoporotic Fractures (SOF). Participants Community-dwelling women aged ≥80 years. Measurements Frequency of nocturia in the previous 12 months, Pittsburgh Sleep Quality Index sleep quality subscale, and actigraphy-measured wake after sleep onset (WASO) and total sleep time (TST). Results Of 1,520 participants, 25% (n = 392) reported their nocturia frequency was 3–4 times/night and an additional 60% (n = 917) reported their nocturia frequency was 1–2 times/night. More frequent nocturia was associated with poor sleep quality (3–4/night: 26.8% reported fairly bad or very bad sleep quality; 1–2/night: 14.7%; 0/night: 7.7%; P < .001) and longer WASO (3–4/night: 89.8 minutes; 1–2/night: 70.6; 0/night: 55.5; P < .001). In nested regression models, a nocturia frequency of 3–4/night quadrupled the odds of poor sleep quality (odds ratio: 4.26 [95% CI 1.65, 11.01]; P = .003) and was associated with a 37-minute worsening in WASO (95% CI 26.0, 49.0; P < .001). Frequency of nocturia explained an additional 6% variation in WASO, above and beyond demographic, medical/psychiatric conditions, and medication factors (∆R2 = 0.06). Conclusions Nocturia is common among octogenarian and nonagenarian women and is independently associated with poor sleep quality and longer wake time at night. Interventions that improve nocturia may be useful in improving sleep quality and wake time at night.

Background Providing high-quality care for patients with Parkinson's disease (PD) involves addressing both motor and nonmotor features. We describe the implementation and evaluation of a 2-day, interdisciplinary Comprehensive Care Clinic (CCC) for patients with PD. Methods Patients who attended the CCC between January 2010 and July 2013 were matched by sex and age with patients who were evaluated in specialist care during the same time frame. Provider documentation of the American Academy of Neurology (AAN) quality measures for PD and Unified Parkinson's Disease Rating Scale (UPDRS) motor scores were compared between specialist and CCC visits at baseline and at 12 months. Results Ninety-five patients participated in the CCC (60% men; 75% white; mean age, 68 years; age range, 38–97 years). Of these, 29 patients were matched to specialist care patients based on the availability of 12-month follow-up data. Both groups were similar with respect to race, marital status, years with PD, and baseline UPDRS motor scores. On average, patients who received CCC care met 10 of 10 AAN quality measures, whereas those who received specialist care met only 5 of 10 quality measures (P < 0.001) over 12 months. At 12-months, there were no significant differences in UPDRS motor scores between the groups (P = 0.5). Conclusions According to the AAN quality measures, the CCC provided higher quality care than the gold standard of specialty care. A randomized controlled trial of the CCC model is warranted to determine its impact on patient-centered outcomes and to assess whether the standard model of care should be altered.

Objective To examine the association between long-term metformin therapy and serum vitamin B12 monitoring. Design Retrospective cohort study. Setting A single Veterans Affairs Medical Center (VAMC), 2002–2012. Participants Veterans 50 years or older with either type 2 diabetes and long-term metformin therapy (n = 3,687) or without diabetes and no prescription for metformin (n = 13,258). Measurements We determined diabetes status from outpatient visits, and defined long-term metformin therapy as a prescription ≥500 mg/d for at least six consecutive months. We estimated the proportion of participants who received a serum B12 test and used multivariable logistic regression, stratified by age, to evaluate the association between metformin use and serum B12 testing. Results Only 37% of older adults with diabetes receiving metformin were tested for vitamin B12 status after long-term metformin prescription. The mean B12 concentration was significantly lower in the metformin-exposed group (439.2 pg/dL) compared to those without diabetes (522.4 pg/dL) (P = .0015). About 7% of persons with diabetes receiving metformin were vitamin B12 deficient (

Nocturia, waking from sleep at night to void, is a common, bothersome symptom for which many older adults seek treatment. In 2017, the US FDA approved the first of two desmopressin analogues indicated for nocturia. While efficacious, these drugs can potentially cause severe hyponatremia that can be fatal, particularly if older adults have comorbid conditions (e.g., congestive heart failure, uncontrolled hypertension), laboratory abnormalities (e.g., low sodium, reduced renal function) and concomitant medications (e.g., diuretics, analgesics). Using secondary data from the National Health and Nutrition Examination Survey (NHANES) to identify a sample of U.S. adults 50 years and older with 2 or more nightly nocturia episodes, we determined the prevalence of contraindications, warnings, and need for more frequent monitoring indicated by the product label. Among the sample of 1,521 older respondents, 70.0% of those with nocturia had contraindications or a need for frequent sodium monitoring. Contraindications to desmopressin analogues were more prevalent with older age (27.6%, 34.5%, and 38.8%, for ages 50-64, 65-79, and 80+, respectively, p

Nocturia (waking from sleep at night to void) is a common cause of sleep disruption associated with increased comorbidity and impaired quality of life. However, its impact on mortality remains unclear. We performed a systematic review and meta-analysis to evaluate the association of nocturia with mortality as a prognostic factor and a causal risk factor.We searched PubMed®, Scopus®, CINAHL® (Cumulative Index of Nursing and Allied Health Literature) and major conference abstracts up to December 31, 2018. Random effects meta-analyses were done to address the adjusted RR of mortality in people with nocturia. Meta-regression was performed to explore potential determinants of heterogeneity, including the risk of bias. We applied the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) framework to rate the quality of evidence for nocturia as a prognostic risk factor for mortality and separately as a cause of mortality.Of the 5,230 identified reports 11 observational studies proved eligible for inclusion. To assess nocturia 10 studies used symptom questionnaires and 1 used frequency-volume charts. Nocturia was defined as 2 or more episodes per night in 6 studies (55%) and as 3 or more episodes per night in 5 (45%). Pooled estimates demonstrated a RR of 1.27 (95% CI 1.16-1.40, INocturia is probably associated with an approximately 1.3-fold increased risk of death.

Urinary symptoms worsen further the quality of life of persons already burdened by neurologic disease. Urinary symptoms frequently occur in the setting of neurologic diseases such as Parkinson disease and Parkinson-plus syndromes, multiple sclerosis, and stroke. Urinary incontinence is associated with increased caregiver burden and enhances the risk of institutionalization among those living with dementia. Nocturia is associated with impaired sleep and work productivity. Providing patient-centered care for urinary symptoms involves assessing patient and family goals for care and incorporating a multicomponent assessment and treatment plan to align treatment options with the goals for care. Lifestyle and behavioral therapies are available as first-line treatment for most urinary symptoms. Consideration of drug therapy should aim to minimize the potential for adverse drug events such as orthostatic hypotension when using α blockers for men with concomitant prostate enlargement or anticholinergic side effects with anticholinergic bladder relaxant therapy. Interventional therapies such as percutaneous nerve stimulation, cystoscopic botulinum toxin injection, and sacral neuromodulation are available for patients who do not have significant urinary retention at baseline. Containment strategies aim to prevent skin irritation and provide support. With a patient-centered approach, providers empower patients to control and contain urinary symptoms and, thus, maintain confidence and social engagement.

Treating urinary incontinence and sexual dysfunction in Parkinson’s disease (PD) involves a multicomponent approach. This incorporates patient goals for care and prioritizes lifestyle and behavioral therapy prior to the initiation of drug therapy in order to avoid adverse drug events. In addition to a targeted exam and careful medication review, assessment of mobility and cognitive function are important to develop patient-centered approaches to care. Pelvic floor muscle exercise-based behavioral therapy is a reasonable first approach to treat urinary symptoms. Drug therapy for urinary incontinence may involve bladder relaxants and/or treatments for concomitant bladder outlet obstruction in men. After evaluation of comorbid conditions and medications affecting sexual function, education regarding treatment options and specialist referral may be considered. Phosphodiesterase inhibitors should be used with caution in men with orthostatic hypotension, and limited evidence suggests efficacy for erectile dysfunction in PD.

The STEADI Options trial uses a randomized, controlled-trial design to assess the effectiveness and cost-effectiveness of the STEADI Initiative . Beginning March, 2020, we will randomize 3,000 adults ≥ 65 years of age at risk for falls seen in an Emory Clinic primary care practice to: (1) full STEADI; (2) a STEADI-derived gait, balance, and strength assessment with physical therapy referrals; (3) a STEADI-derived medication review and management; or (4) usual care. This presentation will discuss decisions made by the study team to facilitate implementation of STEADI including electronically conducting screening prior to the date of encounter, the use of dedicated nursing staff to conduct assessments, implementation of strength, balance, orthostatic hypotension, and vision testing, methods to facilitate medication review, and communication of assessment information to providers. The results from this study will be used to estimate the impact of STEADI on falls, service utilization, and costs over one year.

Diabetes-related lower extremity amputations (LEA) are high cost and high prevalence. Individuals with complications such as neuropathy, foot deformity, history of diabetic foot ulcer or LEA increased morbidity and mortality.1 Current national recommend a foot exam for individuals with diabetes annually or more often depending on risk for LEA.2, The purpose of this pilot study was to examine the relationship between annual foot exams and incident lower extremity amputation in a large Veteran cohort. We conducted a secondary analysis of a national VA Diabetes administrative dataset registry for Veterans with diabetes aged 65 and older during the period of fiscal year 2002-2014 (n=1,544,654; mean age 77.6 years; 97.9 % male). Using logistic regression, we examined the association between annual foot exams and incident LEA. Our analysis was adjusted for demographics, comorbidities, and LEA foot risk. The study included 18,759 (1.21%) Veterans with incident LEA and foot exams, 2,234 (0.14%) Veterans with incident LEA without foot exams. Median age range was 65-75 years old. Gangrene, osteomyelitis, foot ulcers, and neuropathy were the covariates with the highest risk of incident LEA with foot exam. Foot exams did not reduce the risk of LEA when examining Veterans with incident LEA (unadjusted OR of 1.62 (CI 1.56 - 1.69), p

AIM: Our objective was to assess whether increased duration of metformin therapy is associated with incident peripheral neuropathy (PN) in older Veterans with diabetes. METHODS: Using national Veterans Affairs registry data from 2002 to 2015, we examined Veterans (50 + years) with diabetes. Long-term metformin therapy was defined as prescription ≥ 500 mg/day, filled for ≥ 6 consecutive months. Metformin therapy duration was examined both as continuous and categorical measures. Incident PN was defined by medical chart review. We estimated unadjusted and adjusted (variables selected a priori) odds ratios (OR) and 95% confidence intervals (CI) using logistic regression. RESULTS: The study included n = 210,004 individuals (mean ± SD: age: 66.2 ± 8.4 yrs, 96% male) prescribed metformin for 47.0 ± 34.0 months. Nineteen percent developed PN during follow-up. After adjusting for age, body mass index, duration of time receiving health care within the VA, smoking status, alcohol abuse, and vitamin B12 testing and treatment, the number of months of metformin treatment was associated with elevated odds for incident PN (aOR (metformin treatment - continuous) = 1.009 (95% CI = 1.009, 1.010); aOR (metformin treatment – categorical (ref: 6–

Evidence indicates that higher serum 25-hydroxy vitamin D levels may be associated with decreased prevalence of urgency urinary incontinence (UI), but the impact of vitamin D consumption on development of urgency and mixed UI is unclear. The objective was to assess whether greater vitamin D intake was associated with decreased risk of incident urgency and mixed UI over 10 years using 2 large prospective cohorts of middle-aged and older women. We analyzed 38,101 women from the Nurses’ Health Study I (NHS I) and 35,190 women from NHS II who were free of UI at baseline. We followed incident UI, defined as new UI occurring at least monthly, separately by subtype (urgency, mixed, stress UI), from 2002–2012. We categorized vitamin D intake from supplements and diet. We estimated relative risk for developing UI according to vitamin D intake using Cox-proportional hazard models with adjustment for covariates. Median vitamin D intake was 580IU in the older women in NHS I (age range 56–71 at baseline) and 487IU in middle-aged women in NHS II (age range 40–57). Among women taking ≥1000IU of vitamin D, median intake in the older women was 1252IU and 1202IU in the middle-aged women. Among the older women, we found no relation of vitamin D intake to risk of developing UI, across all UI subtypes. In multivariable-adjusted analysis for middle-aged women, the relative risk of developing mixed UI among women taking ≥1000IU was 0.79 (0.63, 0.99) and for urgency UI was 0.88 (0.71, 1.07), versus

Urinary incontinence (UI) is common among women and contributes to decreased quality of life. Several effective treatment options are available for the most common types of UI (stress, urge, and mixed), including lifestyle and behavioral therapy, drug therapy, and minimally invasive procedures. Most women improve with treatment, and UI is not an inevitable part of aging. To maximize the opportunity for successful treatment, it is critical to align the treatment approach with patient goals and expectations for care, including an assessment of patient-driven priorities regarding potential adverse effects, costs, and expected benefit of different treatment approaches.

The DREAMS Team research advocacy training program helps clinical faculty and health students introduce basic clinical research concepts to diverse older adults to galvanize their active involvement in the research process. Older adults are frequently underrepresented in clinical research, due to barriers to participation including distrust, historical mistreatment, and their lack of health literacy. The DREAMS Team program aims to involve diverse older adults throughout all phases of research and increase research participation, thereby contributing to the growth of quality patient-centered, evidence-based health care. This course was developed for clinical faculty to deliver to diverse adults aged 55+ in eight 50-minute lectures, followed by half-hour small group discussions moderated by health students. A pilot cohort of 24 individuals was assessed for satisfaction post-program, and self-efficacy before and after the program. Older adult participants improved on a survey measure of self-efficacy, and indicated satisfaction on a post-program questionnaire. All agreed or strongly agreed that they enjoyed participating, and that classes enhanced knowledge/skills about the topics, were high quality, and provided useful information. Twenty-two out of 24 individuals who completed the program indicated they planned to get involved as research advocates. The DREAMS Team program can be offered either on its own, or as a follow-up program to a general health education course led by health students and/or professional researchers or clinicians. Educating older adults about the research process and advocacy through interactive seminars led by congenial and respectful researchers and health students may remove some barriers to research participation and involvement among diverse older adults.

Older adults frequently experience nocturia and sleep disturbance concurrently, and problems with sleep resulting from nocturia are a major factor accompanying the bother associated with nocturia. A multicomponent treatment strategy is usually warranted. Initial treatment includes lifestyle modification and behavioral treatment with consideration of pelvic floor muscle exercise-based therapy. Early evidence suggests that behavioral treatment results in similar nocturia reductions compared with the most frequently used drug therapies. Providers should consider formal sleep evaluation if initial treatment strategies for nocturia do not result in significant improvement, because specific sleep disorders may predispose to nocturia.

The aim of this study is to determine whether vitamin D status is associated with incident urinary incontinence (UI) among community-dwelling older adults. The University of Alabama at Birmingham Study of Aging is a prospective cohort study of community-dwelling Medicare enrollees. Standardized assessment of UI was conducted using the validated Incontinence Severity Index. The analysis of 25-hydroxyvitamin D [25(OH)D] levels was performed on stored baseline sera. UI was assessed every 6–12 months for up to 42 months. The analyses included multivariable logistic regression and Cox proportional hazard models. Of 350 participants (175 male, 147 black, mean age 73.6±5.8), 54% (189/350) were vitamin D deficient (25(OH)D

Objective: To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician–pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). Methods: This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. Results: Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug–disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). Conclusion: Academic detailing led by a physician–pharmacist pair resulted in improved confidence in physician residents’ ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.

The definition of frailty, as modeled by the Fried criteria, has been limited primarily to the physical domain. The purpose of this study was to assess the additive value of cognitive function with existing frailty criteria to predict poor postoperative outcomes in a large multidisciplinary cohort of patients undergoing major operations.A 4-level composite frailty scoring system was created via the combination of the Fried frailty score and the Emory Clock Draw Test to assess preoperative frailty and cognitive impairment, respectively. Overall survival was defined as months from date of operation to date of death or last follow-up.This study included 330 patients undergoing major operations; mean age was 58 years and a total of 53 patient deaths occurred during 4-year follow-up. Among the robust cohort, 20 of 168 patients died (11.9%), and among those who were both physically frail and cognitively impaired, 11 of 26 patients died (42.3%). Multivariable analysis demonstrated the physically frail and cognitively impaired cohort to have a 3.92 higher risk of death (95% CI 1.66 to 9.26) compared with the cohort of robust patients (p = 0.002). Kaplan-Meier survival curves reveal an overall difference in long-term survival (log-rank p0.0001), driven mainly by the high risk of mortality among patients with both physical frailty and cognitive impairment.The use of a combined frailty and cognitive assessment score has a more powerful potential to predict adult patients at higher risk of overall survival than either measurement alone. The addition of cognitive assessment to physical frailty measure can lead to improved preoperative decision making and possibly early intervention, as well as more accurate patient counseling.

EQUiPPED is a multicomponent quality improvement initiative combining education, electronic clinical decision support, and individual provider feedback to influence prescribing and improve medication safety for older adults. The objective here was to evaluate the effectiveness and sustainability of EQUiPPED to reduce the use of potentially inappropriate medications (PIMs), as defined by the American Geriatrics Society 2012 Beers Criteria, prescribed to older Veterans at the time of emergency department (ED) discharge. This evaluation represents a pre- and post-intervention comparison of PIM prescriptions at 4 urban Veteran Affairs (VA) Medical Center EDs. Poisson regression was used to compare the number of PIMs prescribed to Veterans 65 years or older discharged from the ED for at least 6 months prior to the first EQUiPPED intervention at each site and for at least 12 months following the final EQUiPPED intervention. The implementation timeline varied by site depending on local resources. All 4 sites showed a significant and sustained reduction in use of PIMs. The proportion of PIMs at site one decreased from 11.9% (SD 1.8) pre-EQUiPPED to 5.1% (SD 1.4) post-EQUiPPED (P < .0001); site 2 from 8.2% (SD 0.8) pre to 4.5% (SD 1.0) post (P < .0001); site 3 from 8.9% (SD 1.9) pre to 6.1% (SD 1.7) post (P = .0007); and site 4 from 7.4% (SD 1.7) pre to 5.7% (SD 0.8) post (P = .04). These results suggest a multicomponent program to influence provider prescribing behavior leads to safer prescribing for older adults discharged from the ED and is sustainable across multiple VA ED sites.

We determined the fluctuation of nocturia in a 12-month period in men with lower urinary tract symptoms.Men with lower urinary tract symptoms were allocated to the placebo arm of the United States Department of Veterans Affairs Cooperative Studies Program Benign Prostatic Hyperplasia Study. Reported nocturia frequency using the American Urological Association Symptom Index was collected at 6 time points (2, 4, 13, 26, 39 and 52 weeks). Repeat measurements of nocturia during a 1-year period were analyzed using a generalized mixed linear model.Of the 305 men allocated to the placebo group 256 participants (84%) gave answers for all 6 time points. In the entire sample the mean nocturia count did not significantly vary from baseline (week 2) after adjusting for covariates (p = 0.542). However, there was considerable fluctuation in nocturia during 1 year. Of the 93 men with 3 or 4 episodes at baseline 47% had improvement and 12% had worsening at 1 year. Of the 184 men who reported 2 or greater nocturia episodes at baseline 15% reported 0 or 1 at 52 weeks. Depending on the case definition during followup the probability of nocturia progression varied between 8% and 54% while nocturia regression varied between 2% and 33%.Using repeat questionnaire based assessments we observed considerable fluctuation in nocturia. However, overall there was no significant increase in prevalence in a 1-year period. These findings may be reassuring to providers and patients who elect to delay interventions for nocturia.

We examined the association between military exposure and urinary incontinence in American men.Data from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008 were merged to include 5,297 men 20 years old or older. The question, "Did you ever serve in the Armed Forces of the United States?" (yes/no) was used to assess military exposure. Urinary incontinence was categorized as any or moderate/severe urinary incontinence vs none. Because the impact of military exposure varied by age, multivariate logistic regression models were used to estimate the OR and 95% CI stratified by 3 age groups, including 55 or less, 56 to 69 and 70 years or greater. Analysis was adjusted for race/ethnicity, education, body mass index, self-reported health status, number of chronic conditions, depression and prostate conditions, the latter in men 40 years old or older.Overall 23% of male respondents reported military exposure. Men with military exposure were more likely to report any urinary incontinence (18.6% vs 10.4%) and moderate/severe urinary incontinence (9.0% vs 3.1%, each p0.001) than men without military exposure. After multivariate adjustment in men 55 years old or younger those with military exposure had 3 times greater odds of urinary incontinence (OR 3.28, 95% CI 1.38-7.77). Military exposure did not increase the odds of urinary incontinence in men 56 to 69 years old (OR 0.97, 95% CI 0.44-2.18), or 70 years old or older (OR 0.91, 95% CI 0.55-1.50).Prior military exposure was associated with moderate/severe urinary incontinence in American men 55 years old or younger even after controlling for known risk factors. Case finding is warranted for urinary incontinence in younger men with a history of military service.

Aims To compare the prevalence of urinary and bowel symptoms in a sample of adults with early Parkinson's disease (PD) and healthy controls (HC). Methods Data were obtained from the Michael J. Fox Parkinson's Progression Markers Initiative (PPMI). Prevalent bladder (urinary incontinence (UI) and nighttime voiding) and bowel (constipation and fecal incontinence (FI)) symptoms were defined as occurring at least sometimes when queried using the Scale for Outcomes in PD for Autonomic Symptoms. Results The proportion of men (65% vs 64%) and the mean age (61.0 ± 9.7 vs 60.2 ± 11.2 years) was similar between early PD (n = 423) and HC (n = 195). UI and constipation were more prevalent among early PD versus HC (UI: 26.7% vs 8.2%, constipation: 32.4% vs 11.8%; P's

Epidemiological studies in women have revealed an association between caffeine intake and urinary incontinence, although evidence among men is limited. Therefore, we evaluated the association between caffeine intake and urinary incontinence in United States men.Data were used from male NHANES (National Health and Nutrition Examination Surveys) 2005-2006 and 2007-2008 participants. Urinary incontinence was defined using a standard questionnaire with Incontinence Severity Index scores 3 or greater categorized as moderate to severe. Structured dietary recall was used to determine caffeine consumption (mg per day), water intake (gm per day) and total dietary moisture (gm per day). Stepwise multivariable logistic regression models were used to assess the association between caffeine intake at or above the 75th and 90th percentiles and moderate to severe urinary incontinence, controlling for potential confounders, urinary incontinence risk factors and prostate conditions in men age 40 years or older.Of the 5,297 men 3,960 (75%) were 20 years old or older with complete data. Among these men the prevalence of any urinary incontinence was 12.9% and moderate to severe urinary incontinence was 4.4%. Mean caffeine intake was 169 mg per day. Caffeine intake at the upper 75th percentile (234 mg or more daily) and 90th percentile (392 mg or more per day) was significantly associated with having moderate to severe urinary incontinence (1.72, 95% 1.18-2.49 and 2.08, 95% 1.15-3.77, respectively). In addition, after adjusting for prostate conditions, the effect size for the association between caffeine intake and moderate to severe urinary incontinence remained.Caffeine consumption equivalent to approximately 2 cups of coffee daily (250 mg) is significantly associated with moderate to severe urinary incontinence in United States men. Our findings support the further study of caffeine modification in men with urinary incontinence.

Urinary storage symptoms are the most common and most bothersome urinary symptoms. Many studies on the relation between body weight and urinary symptoms have focused on urinary incontinence in women. We evaluated the association of obesity with urinary storage symptoms in a population based study of men and women age 18 to 79 years old.Questionnaires were mailed to 6,000 adults randomly identified from the Finnish Population Register. Self-reported height and weight were used to calculate body mass index. Urinary frequency, nocturia, urgency, stress urinary incontinence and urgency urinary incontinence were assessed using validated instruments. Multivariate logistic regression analyses (adjusted for age, comorbidity and medications, and sociodemographic, lifestyle and reproductive factors) were performed to evaluate associations between body mass index and each symptom.Of the 6,000 individuals approached 3,727 participated (62.4% response, 53.7% women). In men and women obesity was associated with nocturia (adjusted OR 2.0, 95% CI 1.2-3.3 for men; OR 2.4, 95% CI 1.5-3.8 for women) but not with urgency (adjusted OR 1.2, 95% CI 0.7-2.3 for men; OR 1.2, 95% CI 0.7-2.1 for women). In men obesity was also associated with urinary frequency (OR 2.0, 95% CI 1.0-3.9), and in women it was associated with stress urinary incontinence (OR 1.9, 95% CI 1.2-3.0) and urgency urinary incontinence (OR 3.0, 95% CI 1.2-7.4). However, the number of men with stress urinary incontinence or urgency urinary incontinence was insufficient for precise analyses.This study extends previous research by providing symptom specific associations between obesity and urinary storage symptoms in a population based sample of men and women. Obesity impacts individual urinary storage symptoms differently and these associations may be influenced by gender.

What's known on the subject? and What does the study add? Nocturia is a common and bothersome lower urinary tract symptom, particularly in men. Many single drug therapies have limited benefit. For men who have persistent nocturia despite alpha-blocker therapy, the addition of behavioural and exercise therapy is statistically superior to anticholinergic therapy. Objective To compare reductions in nocturia resulting from adding either behavioural treatment or antimuscarinic drug therapy to α-adrenergic antagonist (α-blocker) therapy in men. Patients and Methods Participants were men who had continuing urinary frequency >8 voids/day) and urgency after 4 weeks of α-blocker therapy run-in and who had ≥1 nightly episode of nocturia. Participants received individually titrated drug therapy (extended-release oxybutynin) or multicomponent behavioural treatment (pelvic floor muscle training, delayed voiding and urge suppression techniques). Seven-day bladder diaries were used to calculate reductions in mean nocturia. Results A total of 127 men aged 42–88 years with ≥1 nocturia episode per night were included in the study. There were 76 men who had a mean of ≥2 nocturia episodes. Among those with ≥1 nocturia episode, behavioural treatment reduced nightly nocturia by a mean of 0.97 episodes and was significantly more effective than drug therapy (mean reduction = 0.56 episodes; P = 0.01). Participants with ≥2 episodes nocturia at baseline also showed larger changes with behavioural treatment compared with antimuscarinic therapy (mean reduction = 1.26 vs 0.61; P = 0.008). Conclusions Both behavioural treatment and drug therapy reduced nocturia in men with ≥1 episode of nocturia/night when added to α-blocker therapy. These results were similar even when only those with ≥2 episodes of nocturia were considered. The addition of behavioural treatment was statistically better than bladder-relaxant therapy for nocturia.

Aim Characterize clinical factors related to nocturia and sleep disruption in Parkinson disease (PD) using polysomnography (PSG). Methods Sixty-three PD patients were recruited regardless of sleep or voiding complaints from a university-based movement disorders clinic for a 48 hr inpatient PSG protocol. Nocturia frequency and bother related to urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) and were corroborated by measurements of PSG-defined sleep made immediately preceding and subsequent to each in-lab voiding episode. PSG measures included whole-night total sleep time (TST), sleep efficiency (SE), apnea/hypopnea index (AHI), and time to PSG-defined sleep following nocturia episodes. Differences between groups were assessed using Mantel–Haenszel chi-square, t-tests, or Wilcoxon signed rank tests. Linear regression was used to assess factors associated with reported nocturia frequency. Results Sixty patients completed the IPSS. Thirty-seven (61%) reported at least two nocturia episodes nightly; those individuals demonstrated lower PSG-defined SE (P = 0.01) and TST (P = 0.02) than patients with 0–1 episodes. Participants reporting 2–3 episodes of nocturia with high bother on the IPSS (n = 12) demonstrated lower whole-night TST (280.5 ± 116.1 min vs. 372.5 ± 58.7 min, P = 0.03) and worse SE (59.2 ± 22.7% vs. 75.9 ± 11.2%, P = 0.04) when compared to participants with 2–3 episodes of nocturia with low bother (n = 13). Conclusions These results verify objectively that PD patients with nocturia have poor sleep. Furthermore, among individuals with comparable levels of reported nocturia, higher bother is associated with poorer sleep as defined on PSG. Neurourol. Urodynam. Published 2013. This article is a U.S. Government work and is in the public domain in the USA. Neurourol. Urodynam. 32:1080–1085, 2013.

Objectives To estimate the prevalence of constipation, fecal incontinence (FI), and combined symptoms and to identify shared factors associated with bowel symptoms in older U.S. men and women Design Population-based cross-sectional study. Setting National Health and Nutrition Examination Survey (2005–2010). Participants Women and men aged 50 and older. Measurements Constipation was defined as hard stool consistency on the validated Bristol Stool Form Scale or stool frequency of fewer than three bowel movements per week. FI was defined as at least monthly loss of solid, liquid, or mucus stool. Combined symptoms was defined as constipation and FI. Multinomial multivarible models adjusted for age, race, socioeconomic status, education, self-rated health, depression, impairments in activities of daily living, and number of comorbidities. Results Women (n = 3,078) reported higher prevalence of bowel symptoms than men (constipation 11.8% vs 4.7%%, FI 11.2% vs 8.6%, combined symptoms 1.4% vs 0.4%). In adjusted models, women had greater odds of having constipation (odds ratio (OR) = 3.0, 95% confidence interval (CI) = 2.3–3.8), FI (OR = 1.4, 95% CI = 1.1–1.8), and combined symptoms (OR = 4.6, 95% CI = 2.0–10.2) than men. Shared risk factors included poor self-rated health and depression symptoms (constipation: OR = 1.8, 95% CI = 1.4–2.4 and OR = 1.8, 95% CI = 1.0–3.2; FI: OR = 1.6, 95% CI = 1.2–2.2 and OR = 2.3 95% CI = 1.4–3.6; combined symptoms: OR = 2.6 95% CI = 1.5–4.8 and OR = 4.6, 95% CI = 1.3–16.4). Conclusion When defining constipation and FI using validated instruments, women had a much higher prevalence of constipation than men, whereas men had a higher prevalence of FI than constipation. Shared risk factors reflect the negative effect that bowel symptoms have on quality of life.

Lithium is a mood stabilizer rarely associated with drug-induced parkinsonism (DIP). We present a case of an elderly woman with bipolar disorder who developed parkinsonian symptoms after chronic lithium administration despite therapeutic serum levels. Upon evaluation, classic parkinsonian signs of muscle rigidity, tremor, bradykinesia, freezing of gait, and cognitive decline were observed. Initially, she was diagnosed with Parkinson's disease (PD); however, DaTscan SPECT imaging clarified the diagnosis as DIP. As the daily lithium dosage was reduced, the patient's motor symptoms improved. This report emphasizes close monitoring of lithium levels in geriatric populations and the need to consider lithium-induced parkinsonism when PD symptoms appear in chronic lithium users.

Quality problem or issue Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Initial assessment Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Choice of solution Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Implementation Geriatric order sets were implemented at two sites as part of the multicomponent ‘Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department’ quality improvement initiative. Evaluation Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups ( n = 20), those ‘EQUiPPED’ with the interventions ( n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record ( n = 10, 5 at each site). All providers were asked about order set ‘use’ and ‘usefulness’. Users ( n = 11) were asked about ‘usability’. Lessons learned Order set adopters described ‘usefulness’ in terms of ‘safety’ and ‘efficiency’, whereas order set consultants and order set non-users described ‘usefulness’ in terms of ‘information’ or ‘training’. Provider ‘autonomy’, ‘comfort’ level with existing tools, and ‘learning curve’ were stated as barriers to use. Conclusions Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.

As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population.To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative.Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time.At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period.This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.