An assessment of relationship between urinary incontinence, and quality of life and psychosocial functioning in elderly women from southeastern Poland

Aging of societies is currently one of the most significant demographic processes. Demographically aged countries are these in which the percentage of people older than 65 has exceeded 12%. Poland reached this threshold at the beginning of 1960s [1]. Currently, this percentage in Poland is 13.5%, and by 2050 it will increase to 34.5% [2]. The region of south-eastern Poland has the longest life expectancy of women - 82.5 years - and it is longer than the country’s mean (81.5 years) [3].

Aging is the natural process of growing older. Each person experiences age-related changes based on many factors which results in weakening the physiological functions of the body [4]. The degree of fitness of the elderly depends on many factors, among other things: aging changes, development of multiple chronic diseases, lifestyle, as well as social, environmental and psychological factors [5]. Chronic disorders that can be developed in older age lead to increasing functional disability, negatively affect quality of life and social functioning [6]. When societies age, the number of people who are functionally and cognitive dependent increases [7]. The incidence of lower urinary tract symptoms (LUTS) and urinary incontinence (UI) increases, too [8].

According to International Continence Society, UI is “a report of any leakage of urine”. It is involuntary urination, regardless of its quantity and reason, that happens once a month or more frequently [9]. The assessment of prevalence of urinary incontinence across the whole society is difficult due to a variety of its definitions [10]. Available studies show that the prevalence of UI in elderly women is between 5% and 69% [11–13]. There has never been a thorough study on this issue in Poland. It is estimated, though, that 5 million Poles suffer from this disorder [14].

Urinary incontinence may lead to lowered self-esteem, increased embarrassment, and social isolation [15]. It generates considerable social and economic costs. Approximately 2% of total health care expenditure, including diagnosis, treatment and hygiene, is spent on elderly patients with urinary incontinence [16]. However, the awareness of elderly people about the treatment and prevention of its occurrence is still low [17]. Falls and UI are the so called Giants of Geriatrics, and together with distortions of cognitive functions and decreased functional ability they constitute key areas for health care regarding the elderly [18]. Coll-Planas et al. [19] found a relationship between decreased functional ability and lowered physical activity and the beginning of UI in elderly subjects. In their study, Foley et al. [20] proved the relationship between falls and urinary incontinence. The feeling of loss of control over one’s bladder and problems in simple and complex activities of daily life may result in worsening of quality of life, in developing anxiety and depression [21].

Earlier studies had analysed the impact of UI on quality of life in elderly people who lived on their own [22] and under institutional care [23]. Still, a more comprehensive assessment of level of functioning of elderly women with urinary incontinence has not been available.

Therefore, our study aimed to analyse quality of life and level of functioning of elderly women with urinary incontinence in respect of activity and participation in daily life.

This cross-sectional study was conducted in south-eastern Poland. According to the data from Central Statistical Office of Poland, life expectancy in this region is the longest in the country [3].

We conducted the study using Paper and Pencil Personal Interview (PAPI). Suitably trained pollsters conducted interviews with a questionnaire designed by our research team and with standardized WHODAS 2.0 and WHOQL questionnaires.

In accordance with Declaration of Helsinki, the subjects were provided with information about the aim and the course of the study, and expressed their informed consent to participate. The approval to conduct the study was obtained from the Bioethical Commission of the University of Rzeszów.

The study was conducted on a representative group of women aged 60 to 80 years living in south-eastern Poland (Podkarpackie region). The criteria for inclusion in the study were the following: female sex, age 60 to 80 years, normal cognitive state, informed consent to participate in the study.

For comparative analysis, we divided this population into two subgroups: I - women with a problem recognized by the doctor considering urinary incontinence (UI) and II - clinical control group (women without problem with urinary incontinence, WP).

We assessed subjects’ self-perceived health and well-being with the use of WHOQOL-bref. This questionnaire is a general instrument of assessment of QOL and comprises 26 questions. Two of them measure the general health. The remaining 24 questions assess four domains:

• Physical health;

• Psychological health,

• Social relationships;

• Environment [24].

For each of the elements one can score 1 to 5 points. Total result is presented on a linear scale from 0 to 100, where 0 denotes the least favourable quality of life, while 100 denotes the most favourable quality of life [25].

We conducted the psychosocial functioning assessment with the WHODAS 2.0. This questionnaire is used for assessment of health and disability. It integrates level of functioning in main life domains, and it is directly linked with ICF.

WHODAS 2.0 covers 6 domains of functioning:

• Cognition - understanding and communicating;

• Mobility - moving and getting around;

• Self-care - hygiene, dressing, eating and staying alone;

• Getting along - interacting with other people;

• Life activities - domestic responsibilities, leisure, work;

• Participation - joining in community activities [26].

The points from 0 to 4 are scored within each of the domains. Scores from individual domains are aggregated. The total score may be between 0 and 100 points, where 0 denotes no disability and 100 complete disability [27]. Apart from the general score, WHODAS 2.0 allows for scoring and presenting results for individual domains.

WHODAS 2.0 approaches each distortion to functioning equally. It has high sensitivity, reliability and intercultural usefulness [28].

The study was run on 1032 randomly selected women aged 60–80 years living in south-eastern Poland (Podkarpackie region). The group was isolated for the purpose of this study analysis from a randomly sampled group of 1800 subjects (1032 women and 768 men). We received the study data from the database run by the Ministry of the Interior and Administration of Poland. We sampled a total of 31 029 subjects (name, surname, address and the PESEL number) - 6 029 subjects aged 60-70 and 25 000 subjects aged 71-80. The reserve sample was 5029 and 24 200 subjects, respectively. We used the SPSS programme to sample the base group without replacement. This kind of sampling allowed for maintaining high methodology standards and made the study representative for south-eastern Poland (Podkarpackie region). The assumed confidence level was 95% (0.95) with estimation error (maximal error) of 3%. The representative results we obtained provided us with information on a large population of people.

In the studied population of women aged 60 to 80 years, 14.53% of subjects reported urinary incontinence. The mean age of the UI group was 72.29 years (SD = 6.06), while the mean age of WP group was 69.26 years (SD = 5.95).

Urinary incontinence increased significantly with age. The UI and WP groups were comparable in terms of place of residence, marital status, education, and income. As the mean age was slightly higher in the study population, there were slight differences between the groups, for example, there were more widows or women with poorer education (table 1).

We found the highest odds ratio for urinary incontinence in women after cerebrovascular accident (CVA). Elderly women with these diseases are almost four times as likely to have urinary incontinence as those without them. We also found very high risk of urinary incontinence in women with degenerative disease of peripheral joints, degenerative diseases of the spine, gastric and duodenal ulcerative disease and neoplastic disease. In women with these diseases, the odds ratio for urinary incontinence is over three times as high as in women without them (table 2).

We found highly significant differences in disability levels between the UI and the WP groups, both in general disability and in individual domains.

The UI group had women of greater disability than the WP group (table 3).

We found highly significant differences in quality of life between the UI and WP groups in the physical health, psychological health, and environment. With the significance level set at p < 0.001 there was no significant difference in social relationships, yet it was clear that in this area quality of life is lower in UP group than in WP group, too (table 4).

According to our best knowledge, our study is the first one to assess disability and quality of life in women with urinary incontinence from the biopsychosocial perspective on disability.Our results have shown that total level of disability was higher in the group of women with urinary incontinence in comparison to the WP group. The level of disability was the highest in the domains that concern activities of daily life, mobility and social participation. In comparison to women without urinary incontinence, elderly women with urinary incontinence experienced greater effect of the dysfunction on areas of quality of life, and in particular in the physical health, psychological health, and environment. It seems, therefore, that urinary incontinence in older women is an important determiner affecting the level of disability and the quality of life.

Our study found that 14.53% of women aged 60 to 80 years reported urinary incontinence. Urinary incontinence is common in elderly people, yet it is difficult to ascertain its exact prevalence due to an accompanying feeling of embarrassment or shame in respondents [29]. An observational study by Women’s Health Initiative found that urinary incontinence affects 29.3% women aged 65 years and over [30]. According to a study by URINO project, the prevalence of urinary incontinence was higher and amounted to 31% [31]. In our study, we found a lower rate of urinary incontinence, yet it may have been due to the embarrassment the elderly respondents felt when answering the questions of the pollster, as well as a lower prevalence of diseases that are risk factors for developing UI (e.g. diabetes or stroke) in the study population [32].

Numerous studies have found that urinary incontinence is related to increased prevalence of disability in elderly women. Gilmour et al. [33] confirmed the relationship between urinary incontinence and disability in simple and complex activities of daily life. According to Omli et al. [34], UI results in losing autonomy and lowering functional abilities. Yet, they found that even though UI is a significant factor that results in lowering abilities to perform simple activities of daily life, it is not related to lowering abilities of complex activities, such as: going shopping, going for a walk or preparing meals.

The factor of urinary incontinence affected all the domains of functioning of the studied women. The effect was the strongest in activities of daily life and participation. Rodríguez-Blázquez et al. [35] analyzed the relationship between chronic diseases, body functions and limitations to activity and to participation in elderly subjects. They found that genitourinary functions may be strongly related to limitations to activity and participation. In their study on elderly urban citizens, Donez et al. [36]. found that most often disability affects activities related to household tasks and daily life participation.

We found a strong relationship between UI and lowered quality of life among elderly women. Numerous studies point out the relationship between urinary incontinence and lowered quality of life [22,23,37]. Frick et al. [38] found no differences in lowered quality of life depending on the kind of urinary incontinence. Barentsen et al. [39] and Grimby et al. [40] confirmed these findings. French, German, British and American studies on groups of women with urinary incontinence found a general tendency for lowered quality of life depending on the intensity of UI symptoms. The strongest correlations were found in domains of family and social life [41].

The study proves that urinary incontinence has significant effect on lowering of quality of life and psychosocial functioning of elderly women living in south-eastern Poland. The results point to those domains of functioning which require greatest support. These conclusions communicate a significant message for those who develop rehabilitation programmes for elderly patients with urinary incontinence.