The prevalence of urinary incontinence (UI) for community-dwelling older women in the United States is reported at ranging from 37% to 41% (Brown et al., 1996; Diokno, Brock, Brown, & Herzog, 1986; Johnson, Bernard, Kincade, & Defriese, 2000). Most of these women do not seek help, even though most clinicians suggest that UI has a significant negative effect on psychological functioning and quality of life (Burgio, Ives, Locher, & Arena, 1994; Diokno et al., 1986; Goldstein, Hawthorne, Engelberg, McDowell, & Burgio, 1992). The most widely held explanations for the lack of help-seeking for UI are embarrassment and the view that UI is a normal (i.e., not amenable to intervention) part of aging. UI also results in a large expenditure of health care dollars each year. Thus, there are costs to both the individual and the health care system as a result of UI.
Despite the prevalence and personal and social costs of UI, very little research examining the relationship between UI, psychological well-being, and quality of life has been conducted. Wyman, Harkins, and Fanti (1990) reviewed early studies describing women's perceptions related to the effects of UI on daily life. These reports were generally based on semi-structured interviews with communitydwelling women, the majority of whom were older. Few reliable and valid instruments were used to examine psychological or social correlates of UI. These studies indicated that UI caused women to restrict social, leisure, household, and work activities and increased social isolation. UI also affected spousal relationships with a marked effect on sexual relationships. In approximately 25% of women, UI was associated with significant depression or anxiety.
A recent study of 668 community-dwelling older adults with UI showed moderate to severe depressive symptoms in 43% (Dugan et al., 2000). In a study of 2,498 adults in Austria using a single item qualityof-life question, 66% of women with UI reported that UI had a negative effect on their quality of life (Temml, Haidinger, Schmidbauer, Schatzl, & Madersbacher, 2000). There is also little evidence that the type of UI (stress versus urge) differentially affects psychosocial functioning (Dugan et al., 2000; Lagro-Janssen, DeBruyne, & Ven Weel, 1992).
More recently, research has focused on the health-related quality of life of individuals with UI. These studies indicate a negative effect of UI on social and emotional functioning (Naughton & Wyman, 1997), but little effect when global quality-of-life measures are employed (Johnson et al., 1998). Some have suggested that global quality-of-life measures do not tap the salient issues of individuals with UI. In a focus group study of older adults with urge incontinence, DuBeau, Levy, Mangione, and Resnick (1998) found that approximately one-half of the patient-identified quality-of-life concerns were not found in typical quality-of-life measures. These included issues related to coping, interpersonal effects, self-concept, self-perceptions, and health perceptions.
UI has also been associated with poorer self-rated health. Self-rated health is an important predictor of mortality and is more predictive than more objective indicators of health status (Diener, 1984; Idler & Kasl, 1991). In a large, cross-sectional sample from that National Survey of Self-Care and Aging, Johnson et al. (1998) found that UI was positively associated with poor self-rated health after controlling for age, comorbidity, and frailty in community-dwelling older adults. That is, UI is an independent marker of poorer self-rated health.
The research so far indicates that UI is associated with poorer quality of life as measured by social functioning, psychological distress, and functional abilities. However, the research has been cross-sectional. Thus, causal relationships have not been determined.
The purpose of this study was to examine the longitudinal relationships between UI and multiple dimensions of physical health, psychological well-being, and psychological distress. This research was based on a secondary analysis of data from a 6-year longitudinal study of older, community-dwelling women's health and well-being. One advantage of this study is that women who volunteered for this study did so based on age only (i.e., a study of older women's health) and not on having a diagnosis or known problem with UI. Thus, this research taps women's experience of UI in the context of aging in general. In addition, this longitudinal study employed multiple measures of both psychological well-being and distress to obtain a broader and more complex assessment of quality of life.
This secondary analysis reports data from a 6-year longitudinal study of older women with chronic illness. Data were collected at three times (1989, 1991, 1995). This research was approved by the Health Sciences Center, Human Subjects Committee, University of Wisconsin-Madison.
Participants in this study were community-dwelling women, ages 60 and older. The sample for this study was composed of 103 women who completed self-report surveys at three times. At Time 1 (« = 179), their average age was 73.3 years (SD = 5.76) with a range of 61 to 93 years. Fifty-four percent were widowed, 57% lived alone, and 97% were retired. These women were somewhat more educated (M = 13.5 years) and had higher incomes than elderly women in the general population (AARP, 1999).
Two years later (Time 2), 149 women (83%) were surveyed again. Four years later (Time 3), 103 usable surveys were returned (70% of Time 2 respondents). The 103 women at Time 3 were compared on all measures to 75 women who dropped out after Time 1. Few differences existed between the original sample at Time 1 and those who remained in the study for all 3 data collection times. At Time 3, the average age was 77.3 (SD = 5.04), 50% were widowed, 54% lived alone, and 43% lived with spouse or family. Twenty-five percent reported incomes less than $12,000 a year, 58% reported incomes from $12 to $40,000 a year, and 15% reported incomes of more than $40,000 a year.
Originally, participants were recruited from various civic, church, and community organizations. At each data collection time, a letter describing the study, a consent form, and questionnaires were mailed with postage-paid envelopes for return mail. Participants' organizations were paid $10 at Time 1 and $5 at Times 2 and 3.
In this study, there were multiple measures of physical health, psychological well-being, and psychological distress.
UI status. One item from a 13item symptom scale was "incontinence" with a four-category response: "don't have," "not all bothered," "a little bothered," and "bothered a great deal." Women were classified as incontinent if they responded to any of the categories, except "don't have." Because this was a secondary analysis, there was no measure of the type or severity of UI, and it is not known how women interpreted this item.
Physical health measures. Health status was assessed by four selfreport measures chosen to assess different dimensions of health: subjective health, the number of health problems, functional health status, and symptom bother. Subjective health was measured by a single item, "In general, how would you rate your health?" on a 5 -point scale (poor to excellent) with higher scores indicating better health. Such measures have been described as one of the best predictors of mortality and morbidity among older adults and are reported to be more predictive than physician ratings of future health status (Diener, 1984; Idler & Kasl, 1991).
The number of health problems was measured using the Older Americans Resources Survey (OARS) schedule of illnesses, an instrument widely used to assess health status in community-dwelling samples of middle-aged and older adults (Duke University, 1978). Two items, osteoporosis and hip fracture, were added to the list of illnesses because of their prevalence in elderly women, resulting in a 20-item checklist. Respondents identified whether or not they experienced each illness in the recent past, and the total number of health problems was computed. Difficulties with activities of daily living (ADLs) was measured by the OARS ADL measure, another widely-used measure of functional health status in community samples (Duke University, 1978). This measure consists of 13 items reflecting different ADLs and instrumental ADLs. Women rated how much difficulty they experienced in carrying out each activity on a 5-point scale (1 = no difficulty, 5 = a great deal of difficulty), and a mean score was computed. The ADL scale has been shown to be reliable and related to other measures of functional status, depression, anxiety, and life satisfaction (Fillenbaum, 1985). The reliability (alpha) coefficient in this sample was .87.
A symptom-bother scale (Heidrich & Ryff, 1993a, 1993b) was used to assess the degree of bother from 12 symptoms typically associated with aging or chronic illness (e.g., aching, pain, stiffness, fatigue). Participants rated how much they were bothered by each symptom on a 0 ("don't have") to 3 ("bothered a great deal") scale with higher scores indicating more bother from symptoms. The reliability (alpha) coefficient in past studies ranged from .78 to .85 and was .86 in this study.
Psychological well-being. Psychological well-being was measured with seven scales. Four scales were developmentally based measures constructed by Ryff (1989) and derived from the literatures on lifespan development, mental health, and personal growth. The dimensions were purpose in life, personal growth, positive relations with others, and autonomy. Purpose in life refers to changing goals in old age related to productivity and creativity, and having intentions or a sense of direction that contribute to a feeling that life is meaningful. Personal growth indicates the ability to continue to develop one's potential or actualize one's self in old age. Positive relations with others emphasizes the achievement of intimacy and generativity, having empathy and affection for others, and the ability to love. Autonomy taps qualities such as self-determination, selfregulation, and independence as well as turning inward in the later years and freeing one's self from the norms of everyday life. To attain a state of well-being or a high level of functioning in old age means being successful in each of these areas.
Favorable reliability and validity coefficients for these scales have been reported (Ryff, 1989; Ryff & Essex, 1991). Each scale consisted of 20 items, divided between positive and negative items, and randomly mixed into a single self-report instrument. Respondents answered according to a 1 (strongly disagree) to 6 (strongly agree) response format. Higher scores indicate higher levels of well-being. In this sample, the internal consistency (alpha coefficients) of these four scales was purpose in life, .90; personal growth, .87; positive relations with others, .91; and autonomy, .86.
PATTERNS OF INCONTINENCE OVER TIME
DEGREE OF BOTHER FROM URINARY INCONTINENCE FOR WOMEN REPORTING Ul AT EACH TIME PERIOD
Two traditional well-being measures, life satisfaction and affect balance, which have been widely used in gerontological research, were also employed. An 11 -item version of Neugarten 's Life Satisfaction Index A (Liang, 1984) was used that measures three dimensions of life satisfaction related to affective and cognitive aspects of subjective wellbeing. Scoring was based on a 1 to 6 scale with higher scores indicating greater life satisfaction.
The Affect Balance Scale (Bradburn, 1969) is also widely used as a well-being measure. It is a 10item scale, half of the items pertaining to positive affect (e.g., feeling pleased about having accomplished something) and half pertaining to negative affect (e.g., feeling very lonely or remote from others). Higher scores indicate more positive affect.
Self-esteem was measured at Time 3 only with Rosenberg's 10item self-esteem scale, which has been used in many studies of adults and elderly individuals (Rosenberg, 1979). Reliability and validity are excellent and are reviewed in Breytspraak and George (1982). Respondents rated the extent of their agreement with each item on a 1 ("strongly disagree") to 4 ("strongly agree") scale, and a mean score was computed. Higher scores indicate higher levels of self-esteem.
Two measures of psychological distress were also included. Depression was measured by the Center for Epidemiological Studies Depression scale (CES-D), a 20item self-report scale designed to measure depressive symptomatology in the general population (Radloff, 1977). Respondents answer each item based on how often they felt or behaved that way in the past week (on a 0 to 3 scale), with higher scores indicating higher levels of depression. This measure is widely used in research on older adults because it emphasizes depressed mood or affect, has few somatically based items, and has had extensive psychometric testing with demonstrated reliability and validity (George, 1989). The internal consistency (alpha) coefficient in this sample was .90. Scores above 15 on the CES-D are considered indicative of clinical depression.
The anxiety subscale of the Jackson Personality Research Inventory was used to measure anxiety (Jackson, 1977, 1979). This anxiety measure was developed for and tested on community samples. In the original psychometric studies, the anxiety subscale demonstrated both convergent and discriminant validity as well as adequate reliability. The reliability (alpha) coefficient in this sample was .87. The anxiety subscale consists of 20-items rated on a 6-point scale (1 = strongly disagree to 6 = strongly agree) and summed for a total score. Higher scores indicate lower anxiety.
DATA ANALYSIS AND RESULTS
All analyses reported are for the 103 participants with data for all three time periods. List-wise deletion was used in the case of missing data.
Patterns of Ul Over Time
In 1989, 26 (27%) women reported a symptom of UI. The reporting incidence doubled over time, so by 1991, 46 women reported UI, and by 1995, the majority of women (n = 61, 62%) reported having this symptom.
A number of different patterns of incontinence occurred during 6 years (Table 1). Twenty-seven women never experienced incontinence (always continent). Nineteen women were incontinent at Time 1 and stayed incontinent (always incontinent). Thirty women were not incontinent at Time 1, but were at Time 3 (became incontinent). Ten women had varying patterns, and the remainder were missing data.
Table 2 indicates how bothered women were by UI as a symptom at each time of measurement. There was some shift from being "not at all bothered" to being "somewhat bothered" over time. The "bothered a great deal" category changed the least with generally 15% of women endorsing this response at each time.
Characteristics of Ul groups at Time 1
Women who identified themselves at Time 1 as having UI (n = 26) were compared to women who, at Time 1, did not have UI (n = 72) on baseline demographic and physical health variables using t tests (Table 3). There were no significant differences on the demographic variables. For physical health, women with UI reported significantly more difficulty with ADLs and more bothersome symptoms than women without Ul.
Effects of Ul on Psychological Weil-Being
To examine the effects of UI on the psychological well-being of elderly women, a series of 2 (UI Group Time 1) by 3 (Time) repeated measures analysis of covariance (MANCOVA) were performed for the physical health, psychological well-being, and psychological distress outcomes. Difficulty with ADLs at Time 1 was the covariate in these analyses to control for baseline frailty. There were significant (p < .05) main effects for UI Group for 3 of the 9 outcomes and a significant UI group by Time interaction for anxiety. To summarize these effects, women with UI in 1989 scored significantly lower 6 years later (1994) on purpose in life, autonomy, and affect balance than women without UI at Time 1. For anxiety, women with UI had significantly worse anxiety than women without UI at Time 1 only.
Group differences in self-esteem were examined using t tests because they were measured only at Time 3. Women with UI had significantly (p < .05) lower self-esteem (i  = 2.18; M = 3.05, SD = .50) than women without UI (M = 3.28, SD = .39; M = 4.47, SD = .75, respectively) Women who reported UI at Time 2 (n = 46) were compared to women without UI at Time 2 (n = 48) on the psychological well-being and distress outcomes over time. A series of 3 (Time) by 2 (UI group Time 2) MANCOVAs with Time 1 ADLs controlled were performed. There were significant main effects of Time 2 UI group on four wellbeing measures and a significant interaction for personal growth (Figure). To summarize these effects, women who reported UI at Time 2 had lower scores on purpose in life, affect balance, and positive relations and higher scores for depression across time. For personal growth, women with Time 2 UI had significantly lower scores at Time 3 only. In addition, t tests indicated that women who developed incontinence at Time 2 had marginally lower self-esteem at Time 3 (M = 3.10, SD = A5;p < .06) than women without UI (M - 3.29, SD = .38, respectively).
TIME 1 DESCRIPTIVE STATISTICS FOR DEMOGRAPHIC AND HEALTH VARIABLES BY TIME 1 URINARY INCONTINENCE (Ul) GROUP
To the authors' knowledge, this is the first longitudinal study examining the effects of UI on older women's psychological well-being and mental health. The domains of psychological well-being included:
* Subjective health.
* Purpose in life.
* Positive relations with others.
* Personal growth.
* Life satisfaction.
* Affect balance.
The overall results indicate that UI has long-term effects on multiple dimensions of psychological well-being. Women who reported UI at Time 1 or by Time 2 had lower levels of psychological wellbeing across 6 years. This suggests that UI exerts broad effects on psychosocial functioning.
Women with UI did not differ from women without UI in age, education, marital status, or income. They did report more bother from symptoms, which included:
* Shortness of breath.
* Problems with concentration and memory.
Women with UI did have more difficulty with ADLs at baseline, which may indicate poorer health status or more frailty in general, although they did not report a greater number of chronic illnesses. Although speculative, it may be that UI contributed to the lower functional health score because UI may have made it more difficult to do housework, shop, or use transportation by limiting a woman's ability to leave home. This has been found in other studies of UI in which women were asked if having UI limited their ability to do things outside of the home (Wyman et al., 1990). This interpretation is supported by the fact that when functional health was controlled in the analyses, the negative effects of UI on well-being persisted.
Figure. Significant differences in psychological well-being over time between women who became incontinent by Time 2 and women who were not incontinent at Time 2.
This research was a secondary analysis of existing data. Therefore, there are a number of limitations. First, it is not known whether women correctly interpreted the incontinence item on the symptom scale. In other UI research, it has been found that women do not report UI when they indeed have it, or they do not characterize their symptoms (e.g., small amounts of leaking urine) as UI (Hart, Palmer, & Fitzgerald, 1999; Herzog & Fultz, 1990). It is most likely that the incidence of UI was underreported in this sample.
Second, the type of UI women experienced, urge or stress incontinence, is unknown. Urge incontinence, compared to stress incontinence, may have a more negative influence on well-being because it is less predictable (Naughton & Wyman, 1997). However, this hypothesis could not be tested.
Third, it is not known whether women were treated for UI. However, given other research findings, it is likely they were not because most older women do not seek treatment for UI (Burgio et al., 1994; Diokno et al., 1986; Goldstein et al., 1992). It is also unknown if women had other illnesses that may be related to UI or were receiving medications that might exacerbate UI. Although the number and types of chronic conditions were assessed, the incidence in this sample of diseases that may be related to UI was very low, so their relationships with UI could not be assessed.
Much of the research on UI has focused on physiological and behavioral interventions. This study indicates that nursing intervention research could benefit from attention to the psychological domain. Psychological factors need to be further studied both as outcomes of interventions (i.e., do interventions targeting UI affect psychological well-being and self-perceptions) and as variables that may influence the success of the intervention (e.g., by influencing adherence to behavioral techniques).
Although this study did not directly address the issue, the results suggest that nurses need to ask older women about UI and how it affects their daily Uves. In a follow-up study 4 years later (n = 60) (Heidrich, 2001), women were asked specific questions about UI. Many women left the questions blank, which suggests that, for older women, there is the same stigma and embarrassment related to issues of UI that has been found in younger women (Ashworth & Hagan, 1993; Skoner & Haylor, 1993). Of the women in this study who responded to the specific UI questions, 20 of 27 who reported a problem with UI also stated they never discussed this problem with their physician or nurse. It is probably safe to assume that these older women were not directly asked by their health care providers whether UI was a problem for them.
If older women experience UI, nurses should be alerted to further address issues of mental health. There are research tools that could be useful in the clinical situation for assessing the effect of UI on quality of life and mental health. These include the Incontinence Impact Questionnaire (Shumaker, Wyman, Uebersax, McClish, & Fanti, 1994) and the Incontinence Quality of Life Instrument (Patrick et al., 1999). Both are multiple-item, Likert-type instruments that assess the effect of UI on numerous important life domains (e.g., physical activity, travel, social relationships, emotional health). One or two items could be selected for use in a clinical evaluation (e.g., "I worry about not being able to get to the toilet on time).
These instruments could also be adapted for clinical use to assess UI 's overall effect on well-being or to guide a discussion of management strategies. Again, this could be performed in the clinical setting by selecting a small subset of items or by having women complete the entire instrument at home (privacy may improve the quality of responses) and returning it by mail before the next clinic appointment. Finally, although the research remains to be conducted, it may be that interventions to improve continence would have long-term effects on psychological well-being and, thus, quality of life in old age.
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PATTERNS OF INCONTINENCE OVER TIME
DEGREE OF BOTHER FROM URINARY INCONTINENCE FOR WOMEN REPORTING Ul AT EACH TIME PERIOD
TIME 1 DESCRIPTIVE STATISTICS FOR DEMOGRAPHIC AND HEALTH VARIABLES BY TIME 1 URINARY INCONTINENCE (Ul) GROUP