Full text of DOI:10.1017/S0714980800000672

Articles
Predictors and Incidence of Urinary Incontinence in
Elderly Canadians With and Without Dementia – A
Five-Year Follow Up:
The Canadian Study of Health and Aging
Truls Østbye
Duke University
Steinar Hunskaar
University of Bergen
Elizabeth Sykes
University of Ottawa*
RÉSUMÉ
Inspirée de l’Étude sur la santé et le vieillissement au Canada, cette étude visait à déterminer l’importance des facteurs
sociodémographiques et médicaux et de l’état cognitif et fonctionnel comme prédicteurs du développement de l’inconti-
nence urinaire et à établir des prévisions d’incontinence sur cinq ans, selon le sexe et l’âge. Les sujets de l’Étude sur la
santé et le vieillissement au Canada qui avaient subi un examen clinique en 1992 et qui ne souffraient pas d’incontinence
urinaire à l’époque ont fait l’objet d’un suivi et leur état a été réévalué en 1997. On a établi les résultats en modèles distincts
de régression logistique à plusieurs variables pour les hommes (n = 306) et les femmes (n = 520) survivants en ce qui a trait
à l’incontinence quotidienne et à l’incontinence quotidienne ou inférieure. On a introduit des variables prédictives dans
les catégories suivantes: facteurs sociodémographiques, état cognitif, état fonctionnel, diabète et ACV. On a également
établi des prévisions d’incidence cumulative d’incontinence de cinq ans pour l’incontinence quotidienne et pour l’incon-
tinence quotidienne ou inférieure, selon l’âgeet le sexe. Les résultatsindiquent que l’incidenced’incontinenceurinaireest
plus élevé chez les femmes que chez les hommes et qu’elle augmente avec l’âge dans les deux groupes. Particulièrement
chez les hommes, les aîné(e)s en établissementssont beaucoup plussusceptiblesde développer de l’incontinence urinaire
que ceux qui demeurent dans leur milieu. L’incontinence augmente fortement lorsqu’il y a démence grave et pas néces-
sairement autant en cas d’immobilité physique. Le diabète sucré entraîne l’incontinence chez les hommes mais non chez
les femmes. Un ACV s’associe à l’établissement de l’incontinence chez les deux sexes. En guise de conclusion, l’inconti-
nence urinaire est commune chez les aîné(e)s et il faudrait déceler sa présence par des examens de routine et l’évaluation
médicale des aîné(e)s. Les patients qui développent de l’incontinence souffrent souvent de démence et de déficience phy-
sique. La portée de l’évaluation et la gestion devraient être soigneusement établies en fonction de chaque patient.
ABSTRACT
Based on the nationalCanadian Study of Health and Aging, theobjective of thisstudy was todeterminethe importance of
socio-demographic and medical factors, cognitive and functional status as predictors of the development of urinary
incontinence, and to estimate five-year incidence by sex and age group. Participants from the Canadian Study of Health
and Aging who underwent a clinical examination in 1992 and were continent for urine at the time were followed up and
their continence status was again determined in 1997. Multivariate logistic regression models with daily incontinence
and daily or less than daily incontinence as the outcomes were developed separately for male (n = 306) and female (n =
520) survivors. Predictor variables were introduced in the following chunks: socio-demographic factors; cognitive status;
functionalstatus, diabetes andstroke. Five-yearcumulativeincidence ofdailyandlessthan dailyincontinenceby sex and
age group was also estimated. Results indicated that the incidence of urinary incontinence was higher in women than in
men, and increased by age in both men and women. Especially among men, those in institutions were much more likely
to develop urinary incontinence than those in the community. Incontinence increased dramatically with severity of
dementia, less so with physicalimmobility. Diabetes mellituswas related tothe development incontinencein men butnot
in women, prior stroke was related to development of incontinence in both sexes.
Canadian Journal on Aging/ La Revue canadienne du vieillissement 21 (1)
95

96 Canadian Journal on Aging 21 (1)
Truls Østbye et. al.
It is concluded that urinary incontinence is common in older persons, and enquiries about its presence should be part
of routine medical and nursing assessment of older persons. Those who develop incontinence commonly have demen-
tia and are physically impaired. The extent of assessment and management should be carefully tailored to each indi-
vidual patient.
*The data reported in this article were collected as part of the Canadian Study of Health and Aging. The core study was
funded by the Seniors' Independence Research Program, through the National Health Research and Development
Program (NHRDP) of Health Canada (project no. 6606_3954_MC(S)). Additional funding was provided by the Divi-
sion of Aging and Seniors, Health Canada. Pfizer Canada Incorporated through the Medical Research Council/ Phar-
maceutical Manufacturers Association of Canada Health Activity Program, NHRDP (project no. 6603_1417_302(R)),
Bayer Incorporated, and the British Columbia Health Research Foundation (projects no. 38 (93_2) and no. 34 (96_1)).
The study was co-ordinated by the University of Ottawa and the Division of Aging and Seniors, Health Canada.
Manuscript received: 17/09/99
Manuscript accepted: 16/09/00
Keywords: Incontinence, Urinary; Aging; Dementia; Longitudinal Study; Canada.
Mots clés: incontinence, urinaire, vieillissement, démence, étude longitudinale, Canada
Requests for offprints should be sent to:/Les demandes de tirés-à-part doivent être adressées à:
Dr. Truls Østbye
Department of Community and Family Medicine
DUMC 2914
Duke University
Durham, NC 27710
U.S.
(ostby001@mc.duke.edu)
nary diseases such as recurrent genitourinary tract
infections [17], as well as with stroke [7, 10, 12] and
diabetes mellitus [7,12].
Background
Urinary incontinence has been defined as the involun-
tary loss of urine, which is objectively demonstrable
and a social and hygienic problem [1]. It is a common
and distressing problem in older persons, with
reported prevalence, depending on the population
studied and the strictness of diagnostic criteria, rang-
ing from 6–37 per cent in the community [2–5] and
from 20–60 per cent in long-term institutions [6]. The
prevalence in men is usually reported to be about one-
half of that in women [7]. Incontinence is frequently
an important factor in deciding whether to institution-
alize older persons [7, 8] .
Most of these reported associations have been based
on cross-sectional data. Cross-sectional analyses of
data from the Canadian Study of Health and Aging
reported baseline prevalence of incontinence as well
as cross sectional correlates of incontinence at baseline
[18]. In women, prevalences of daily incontinence
were 2.4 per cent in those aged 65–75 years, 9.4 per
cent in those 75–84 years and 23.5 per cent in those 85
years of age and older, the corresponding numbers in
men were 4.2, 5.3 and 14.8 per cent. The prevalence
increased with severity of dementia and decreasing
ambulatory function. In this follow-up, we document
the risk, among those older persons who were conti-
nent at baseline, of developing incontinence within a
five-year period, relative to demographic, functional
and cognitive status as well as certain specific dis-
eases present at baseline.
A series of different studies from many countries have
shown associations between urinary incontinence and
other health factors in older persons. The prevalence
of incontinence increases with age [4, 9–12], is usually
reported to be more common in women [11,12] and is
much more common in older persons living in institu-
tions than in those living in the community [12, 13].
Strong correlations between incontinence on the one
hand and general physical [9–11, 13, 14] and cognitive
impairment (especially dementia) [10, 11, 14–16] on
the other, have also been consistently observed. Asso-
ciations have also been found with specific genitouri-
Materials And Methods
The Canadian Study of Health and Aging (CSHA) is a
multicentre epidemiological study of dementia and
other health problems in elderly Canadians [19–21].

Incontinence in Elderly Canadians
La Revue canadienne du vieillissement 21 (1)
97
The study surveyed 10,263 randomly selected older
persons aged 65 and over across Canada (excluding the
Northwest and Yukon territories) in 1991 (CSHA-1).
There were 9,008 living in the community and 1,255 in
long-term care institutions. An extensive neurological
and neuropsychological examination was performed
on all subjects in the long-term care institutions, those
in the community who screened positive for cognitive
impairment (according to the Modified Mini-Mental
State Examination [22]) and a subsample of those in the
community who screened negative. The clinical exami-
nation was performed on 2,914 subjects.
In preliminary multivariate analyses, there was an
interaction among several predictor variables and sex.
The data were therefore analysed separately for men
and women. This is also logical given the differences
in anatomy and physiology of micturition between
men and women.
The unadjusted, univariate, proportions of individu-
als with (1) daily or (2) daily or less than daily inconti-
nence in various subgroups based on the predictor
variables included were calculated. Using logistic
regression analysis, development of (1) daily inconti-
nence or (2) daily or less than daily incontinence at
CSHA-2 were chosen as the outcomes. Predictor vari-
ables (at CSHA-1) were introduced in conceptual
chunks. Socio-demographic variables included age
group (65–74, 75–84, 85+) and institutional status.
Cognitive function was classified as normal, cognitive
impairment no dementia (CIND), mild dementia and
moderate dementia [23]. The diagnosis CIND was
used for a broad, heterogeneous, group of older per-
sons who were diagnosed clinically with cognitive
impairment that did not meet the criteria for demen-
tia; examples of such cognitive impairment include
that due to alcohol abuse, depression or age-associ-
ated memory impairment. Nearly all of those who
were diagnosed as having severe dementia in CSHA-1
were already incontinent at baseline, or were dead at
CSHA-2, and were therefore not included in the anal-
yses. Other health variables included physical mobil-
ity, diabetes and stroke. SAS (version 6.12; SAS
Institute Inc., Cary, NC) under SunOS (UNIX) was
used for data management and analysis.
In 1996, five years after the baseline assessments, all
subjects were recontacted (CSHA-2). Again, everyone
in institutions as well as those who scored positive for
cognitive impairment in the community and a sub-
sample of those in the community who screened neg-
ative, underwent an extensive neurological and
neuropsychological examination. For those who had
died since CSHA-1, the Registrar General in each
province was contacted to provide information about
death from the death certificates.
The study was approved by the ethics review boards
committees in the 18 participating centres.
For the present incontinence analyses, those subjects
were selected who (1) underwent a clinical examina-
tion in CSHA-1 and were continent for urine and (2)
were still alive and had continence information in
CSHA-2. Five hundred and twenty women and 306
men were included.
Based on a combination of the available data on uri-
nary incontinence (primarily from the clinical assess-
ment, but supplemented with data from an interview
with the main caregiver), each subject was classified
as (1) having daily incontinence; (2) having less than
daily incontinence; (3) incontinent with unknown fre-
quency (not included in the following analyses); or (4)
continent. If the subject was incapable of answering,
the questions were directed to the subject’s caregiver.
The questions to the subjects were: “Do you have any
difficulty with incontinence of urine?” If “Yes,” “Is it
daily, less than daily but more than once a month, or
less than once a month?”. Subjects with an indwelling
catheter were classified as having daily incontinence.
Those who were incontinent less than once a month
were considered continent.
Results
A relatively large proportion of those who were conti-
nent at CSHA-1 died prior to CSHA-2 (885/1999 =
44%, weighted: 41%). The five-year mortality
(weighted) ranged from 16 per cent in women who
were 65–74 at CSHA-1 to 66 per cent in men who were
over 85 at CSHA-1. No continence information was
available for those who died, and the results therefore
relate to those who were still alive at CSHA-2.
The five-year cumulative incidence of urinary inconti-
nence was higher in women than in men, and
increased by age in both sexes (Table 1). The propor-
tion who developed daily incontinence ranged from
14 per cent in men who were 65–74 at CSHA-2 to 52
per cent in women over 85 at CSHA-1; daily or less
than daily incontinence from 16 to 56 per cent.
The weighted five-year cumulative incidence rates of
daily and less than daily urinary incontinence were
calculated by sex and age group. The sample weights
were adjusted for age, sex, region and institutional
status in CSHA-1.

98 Canadian Journal on Aging 21 (1)
Truls Østbye et. al.
Table 1: Five year cumulative incidence of urinary incontinence by gender and age-group (weighted data).
Five-year Cumulative Incidence of Urinary Incontinence
Females
Males
Age group (at baseline) Daily incontinence
Less than daily
incontinence
Daily incontinence
Less than daily
incontinence
65–74 years
75–84 years
85+ years
28%
31%
52%
13%
12%
4%
14%
17%
29%
2%
8%
11%
Table 2: Percent of women who developed incontinence five years after CSHA-1 in the different
sub-groups. Relative odds of developing urinary incontinence adjusting for other variables in the models.
Daily Incontinence (CSHA-2)
Daily or Less than Daily Incontinence (CSHA-2)
Predictor
variables
(CSHA-1)
%
incont.
Odds Ratios
%
incont.
Odds Ratios
Model 1
Model 2
Model 3
Model 1
Model 2
Model 3
(n = 463)
(n = 463)
(n = 459)
(n = 520)
(n = 520)
(n = 459)
Age 65–74
Age 75–84
Age 85+
22.7
ref. §
1.3
ref.
ref.
32.0
ref.
ref.
ref.
27.5
42.2
26.1
40.2
1.1
1.1
35.6
47.8
35.0
44.8
20.5
46.4
59.6
77.8
30.9
62.6
1.2
1.0
1.0
2.6**
ref.
1.8
1.7
2.0**
ref.
1.4
1.4
Community
Institution
ref.
ref.
ref.
ref.
2.0**
1.6
1.2
1.6*
1.2
1.0
Normal cognition 11.6
ref.
ref.
ref.
ref.
CIND §§
38.6
53.7
3.1***
6.4***
15.9***
2.9***
5.1***
11.7***
ref.
2.6***
4.7***
10.7***
2.4***
3.8***
8.0***
ref.
Mild dementia
Moderate dementia 75.6
Physically mobile 22.0
Physically
immobile.
58.7
3.8*
2.8***
No diabetes
30.4
ref.
0.7
ref
38.3
32.6
35.7
58.0
ref.
0.7
ref.
1.7
Diabetes mellitus 26.7
No stroke
Stroke
27.8
53.3
2.1
* p < 0.05
** p < 0.01
*** p < 0.001
§ Reference category
§§ Cognitive Impairment, No Dementia

Incontinence in Elderly Canadians
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99
Table 3: Percent of men who developed incontinence five years after CSHA-1 in the different subgroups.
Relative odds of developing urinary incontinence adjusting for other variables in the models.
Daily Incontinence (CSHA-2)
Daily or Less than Daily Incontinence (CSHA-2)
Predictor
variables
(CSHA-1)
%
incont.
Odds Ratios
%
incont.
Odds Ratios
Model 1
Model 2
Model 3
Model 1
Model 2
Model 3
(n = 286)
(n = 286)
(n = 286)
(n = 306)
(n = 306)
(n = 305)
Age 65–74
12.0
13.3
22.2
9.8
ref. §
1.3
ref.
ref.
15.4
ref.
ref.
ref.
Age 75–84
1.1
1.1
19.8
30.0
14.3
48.9
11.4
18.9
46.2
73.3
15.5
45.2
18.2
29.0
17.8
36.7
1.5
1.2
1.2
Age 85+
2.3
1.7
1.8
2.6*
ref.
1.9
2.0
Community
ref.
ref.
ref.
ref.
ref.
Institution
40.0
7.7
6.4***
6.6***
ref.
6.4***
ref.
6.0***
6.1***
ref.
5.7***
ref.
Normal cognition
CIND §§
15.1
33.3
63.6
10.8
1.6
1.7
1.3
1.3
Mild dementia
Moderate dementia
Physically mobile
5.2**
22.1***
4.8**
18.3***
ref.
6.2***
19.2***
5.1**
14.6***
ref.
Physically immobile 36.1
2.6*
ref.
2.6*
ref.
No diabetes
Diabetes mellitus
No stroke
12.1
29.0
13.0
24.0
3.0*
ref.
1.8
ref.
Stroke
1.3
1.5
* p < 0.05
** p < 0.01
*** p <0.001
§ Reference category
§§Cognitive Impairment, No Dementia *
Especially among men, those in institutions were
much more likely to develop urinary incontinence than
those in the community (Tables 2 and 3). This relation-
ship remained after the functional and disease varia-
bles were included in the models for men, but
disappeared for women. The risk of incontinence
increased dramatically with severity of dementia, and
was an especially common development among those
with moderate dementia at baseline. Physical immo-
bility at baseline was associated with a threefold
increase in the risk of developing incontinence. Diabe-
tes mellitus was associated with the development of
incontinence in men. In univariate analyses, a previous
stroke doubled the occurrence of incontinence in both
men and women, with more than half of women with
stroke developing incontinence. Although this rela-
tionship remained in the multivariate analyses, it was
no longer statistically significant. There were no signif-
icant interactions among the socio-demographic varia-
bles.
Discussion
Urinary incontinence is more than a physical problem.
It has widespread psychological and social effects as
well, such as isolation, feelings of loneliness and dis-
turbed relationships with friends and relatives. It also
increases the demand for nursing and home services
[24, 25].
What constitutes clinically significant incontinence
has been discussed elsewhere, but remains undefined
[26]. Caution must be shown when using self- and
proxy reported data, but we believe that the combined
information regarding incontinence from the clinical
history and the caregiver interview strengthens the
validity of the incontinence diagnosis used for these
analyses.
Since continence information was not available for
those who died between CSHA-1 and CSHA-2, our
findings relate only to those who survived. Arguably,
those who died may have been more likely to develop

100 Canadian Journal on Aging 21 (1)
Truls Østbye et. al.
incontinence than those who survived, i.e. the cumu-
lative incidence rates are low estimates.
persons with dementia and incontinence cannot gain
better control of their incontinence [29], especially
since improved mobility can be considered an impor-
tant mediating factor for incontinence in dementia.
The finding that incontinence is closely associated
with poor mobility suggests that improvement in
mobility can improve incontinence in elderly women
[4]. For example, in a study of cognitively impaired
nursing home residents, a daily exercise program
designed to improve walking had a significant impact
on reducing daytime incontinence [30].
In most earlier studies, information about inconti-
nence and its correlates were collected in a cross-sec-
tional fashion. A strength of our analysis is that it
relates predictors, collected at baseline from individu-
als who at that time were continent, to the presence of
incontinence measured at follow-up five years later.
The risk of developing incontinence clearly increases
with age, but when other factors are adjusted for, age
per se becomes less important. Although the risk is
higher in women than in men, the increase with age
appears to be steeper in men than in women. Simi-
larly, older persons in institutions have a highly
increased risk of developing incontinence. In women,
being in an institution loses its significance when
adjusting for other risk factors, but it remains a strong
risk factor in men. The institutional environment may
make older persons more dependent and thus more
likely to develop incontinence. However, institution-
alization is closely related to general frailty and it can
therefore not be concluded from our data that institu-
tionalization per se leads to incontinence.
It has been suggested [31] that in many geriatric
patients urinary incontinence is more closely related
to general functional impairment than to specific
medical conditions of the uro-genital organs and the
central nervous system. It is therefore important that
the physician consider the patient from a broad per-
spective and not focus only on the “bladder level”.
With proper assessment many older persons with
incontinence can be significantly improved by sur-
gery, medication or conservative measures. Services to
deal with incontinence, including incontinence teams,
urodynamic clinics and community incontinence
nurses, are becoming more common [32, 33]. Effective
delivery of such services requires identification of
people with the disorder and this is assisted by
knowledge of who is at increased risk. Subjects
referred to incontinence clinics are usually a select
group, and older persons with dementia may be less
likely to be referred. Most of these interventions
require active patient participation and thus some
level of intact cognitive capacity [15]. As one would
expect, in a study of behavioural therapy to reduce
incontinence, those with better cognition showed
markedly better results from the intervention [32],
and Seidel et al. [15] suggest that intact cognitive func-
tion appears to be an important factor in successfully
maintaining or regaining continence. However, the
important implication of these findings is that in
patients with dementia, improvement in mobility
may well lead to a reduction in incontinence [29].
The strongest risk factor for the development of
incontinence is cognitive impairment, and specifically
dementia. Incontinence and dementia are closely
associated, but the relationship may be through vari-
ous mechanisms. Confusion, an inability to plan mic-
turition, poor mobility and an inability to find the
toilet can precipitate urinary incontinence in older
persons with some underlying detrusor instability.
Loss of sphincter control is considered to be a hall-
mark of the later stages of dementia, especially of
Alzheimer’s disease [27].
The distinction between “incontinence secondary to
dementia” and “incontinence associated with demen-
tia” has been emphasized [28]. This difference may be
more than semantic. A belief in the former may easily
lead to therapeutic nihilism. Not considering the com-
plicated interrelationship among age, disease, medi-
cations and functional and cognitive impairment, may
lead to a neglect of both potential therapeutic modali-
ties and improved patient outcomes. Incontinence
may in many cases be more related to the functional
dependence than to neurological and neuromuscular
changes due to dementia per se [17]. The realisation
that the link between dementia and incontinence is
confounded by other factors, especially functional
impairment, is possibly already leading to a more
aggressive approach to incontinence in nursing
homes [28].
Conclusion
These findings may help identify older persons at
greater risk for developing incontinence and may also
potentially be used to develop assessment tools that
will help identify older persons at risk for developing
incontinence. Since urinary incontinence is a common
disorder in older persons, enquiries about inconti-
nence should be part of routine medical and nursing
assessment. Those who develop incontinence com-
monly have dementia and are physically impaired.
The extent of assessment and management should be
carefully tailored to each individual patient.
Even if our longitudinal data imply that incontinence
follows dementia, this does not mean that many older

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101
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