Neurological disorders and injury are common in the long-term care setting (Jones et al., 2009), where more than 1.4 million Americans reside. Two common sequelae of neurological conditions, such as spinal cord injury (SCI), stroke, cerebral palsy, multiple sclerosis, and traumatic brain injury (TBI), are spasticity and urinary incontinence (UI) (Chua et al., 2003; Jensen et al., 2013; Marciniak et al., 2014; Mehdi et al., 2013; Meng et al., 2010; Sommerfeld et al., 2004). Spasticity and UI are both characterized by muscular hypertonicity, and therefore, are also managed with treatments that relax hyperactive muscles (i.e., onabotulinumtoxinA) (Orasanu & Mahajan, 2013; Rekand, 2010).
Not surprisingly, spasticity and UI are also common in the long-term care setting, affecting up to one third and more than one half of residents, respectively (Gill et al., 2020; Meijer et al., 2017; Sayce et al., 2016; Temml et al., 2000; Turchan, 2016). Despite their high prevalence in this setting, both conditions are widely underdiagnosed and therefore often left untreated, despite the availability of U.S. Food and Drug Administration (FDA)–approved therapies (Gill et al., 2008; Gill et al., 2020; Lukacz et al., 2017; Meijer et al., 2017; Minassian et al., 2012; Orasanu & Mahajan, 2013; Rekand, 2010; Turchan, 2016). Interestingly, numerous case series describe improvement in bladder dysfunction in patients with spasticity treated with intrathecal baclofen, which also relaxes muscle hyperactivity (Bushman et al., 1993; Mertens et al., 1995; Nanninga et al., 1989; Schreiber et al., 2009; Talalla et al., 1990). Although the negative impact of spasticity (Gill et al., 2020; Meijer et al., 2017) and UI (Busby-Whitehead et al., 2015) are separately reported, the prevalence of comorbid spasticity and UI in the long-term care setting is not well described.
The current study's objectives were to report: (a) the prevalence of comorbid spasticity and UI in a long-term care facility, and (b) how their concurrence is associated with activities of daily living (ADL) dependency and health-related quality of life (QoL). A better understanding of co-occurring spasticity and UI will facilitate improved diagnosis and management rates for these common, treatable conditions in the long-term care setting.
Population and Setting
The current cross-sectional, observational study was approved by the Vanderbilt Institutional Review Board. All 129 residents of a long-term care facility for Veterans at the time of enrollment (December 2017 to February 2018) were invited to participate. Written informed consent was obtained for all participants. Researchers directly approached all residents competent to make their own medical decisions (46%, 59 of 129). For residents not competent to provide consent (54%, 70 of 129), their legally authorized medical decision-maker (MDM) was mailed informational letters and informed consent forms. To enhance proxy-consented enrollment, researchers also approached MDMs present at the facility during regularly scheduled study visits.
Demographics and relevant medical diagnoses were extracted from participants' medical records, International Classification of Diseases (ICD) 9/10 codes, and the most recent Minimum Data Set (MDS) 3.0 at the time of the visit (Morris et al., 1999). The MDS is a detailed health assessment administered to all residents of Medicare or Medicaid certified long-term care facilities.
Spasticity diagnosis was determined through a physical examination conducted by a movement disorders neurologist (P.H.) who had no prior knowledge of participants. The neurologist evaluated spasticity by noting the following symptoms in upper and lower limbs: deep tendon reflexes, increased muscle tone, exaggerated tendon jerks, clonus, stretch reflex spreading to extensors, loss of dexterity, loss of selective control of muscles and limb segments, Babinski response, mass synergy, weakness, rheological changes, and abnormal postures. The neurologist also used the Modified Ashworth Scale to rate the worst-affected limb for participants diagnosed with spasticity. Previous evidence of spasticity was determined by presence of spasticity-associated ICD 9/10 codes (Table A, available in the online version of this article) and/or symptom-related notes in the medical record, verified by a separate movement disorders specialist. The following neurological disorders known to be associated with spasticity were recorded from ICD 9/10 codes to document potential etiology: stroke, multiple sclerosis, cerebral palsy, TBI, SCI, and spinal stenosis.
Spasticity-Related ICD 9/10 Codes
Participants were classified as having UI from the MDS 3.0 Section H300 if the item, “Select the one category that best describes the resident,” was marked occasionally incontinent, frequently incontinent, or always in-continent, or if UI-related ICD 9/10 codes (Table B, available in the online version of this article) were identified in the medical record. A secondary classification designated participants with severe UI, as indicated by the MDS 3.0 Section H300 marked always incontinent. Six participants were not rated for the UI item. Comorbidity was defined as participants with both a spasticity diagnosis by the movement disorders specialist and having UI on record. The following categories of medical conditions known to be associated with UI were recorded from ICD 9/10 codes to document potential etiology: cerebrovascular disorder, central nervous system (CNS) trauma, dementia, diabetes, Parkinson's disease, prostate disorders, and urinary tract infection.
Urinary Incontinence-Related ICD9/10 Codes
Activities of Daily Living
MDS 3.0 Section G contains detailed information on the resident's capacity to complete ADLs. Eight ADL domains (dressing, personal hygiene, toilet use, transfer, locomotion on unit, bed mobility, eating, bathing) were scored by a care provider who observed the patient over a 7-day period. Scores of 7 (occurred once or twice) or 8 (did not occur) were recoded as a score of 4 (total dependence). ADL Dependency Score is a measure of functional independence and sums all ADL scores except for bathing (Morris et al., 1999). Scores range from 0 (totally independent) to 28 (totally dependent).
Health-Related Quality of Life
The EuroQoL-5D-5L (EQ-5D) questionnaire was administered to participants or, if appropriate, their MDM to assess health-related QoL (Van Hout et al., 2012). Each of the five domains (anxiety/depression, mobility, usual activities, self-care, and pain/discomfort) were rated on a 5-point ordinal scale: no problems, slight problems, moderate problems, severe problems, or extreme problems (i.e., unable to complete activity) (Van Hout et al., 2012). Responses with ratings from 1 to 5 were used to create a 5-digit EQ-5D score. A utility index was then calculated, converting the EQ-5D score into a number (US Crosswalk Index Value Calculator, version 1.0; maximum value of 1 representing the highest QoL) (Van Hout et al., 2012). Participants or MDMs were also asked to answer the Euro-QoL visual analog scale (EQ-VAS) on the day of the interview. EQ-VAS ranges from 0 to 100 (0 = the worst health you can imagine, 100 = the best health you can imagine).
Fisher's exact test was used to compare proportions. Separate proportional odds models were fit for the dependent variables, ADL dependency score and EQ-5D, with age, spasticity (present/absent), and UI (present/absent) as independent variables. If spasticity or UI had p < 0.05, a proportional odds model using a spasticity × UI interaction term was fit for that dependent variable. Mean differences of the ADL dependency score, the seven components of the ADL dependency score, EQ-5D, and EQ-VAS in participants with versus without comorbid spasticity and UI were assessed using bootstrap percentile resampling with 10,000 replications. Multiple comparisons correction was performed using the false discovery rate (FDR) procedure. Analyses were conducted using R statistical software (version 3.5.2), with an a priori significance threshold of p < 0.05.
The current study population includes 49 participants who received a spasticity determination by a neurologist specializing in movement disorders (Figure 1). Participants were 80% male (39 of 49), with a mean age of 78.2 (SD = 9 years) (Table 1).
Spasticity was present in 35% of participants (17 of 49), but only 29% (five of 17) of those participants had evidence of a prior diagnosis documented in their medical record. Among participants with spasticity, 71% had upper limbs affected (12 of 17), 53% had lower limbs affected (nine of 17), and 23% had upper and lower limb spastic postures (four of 17). Three participants with spasticity were receiving oral baclofen treatment (18%), and none were receiving neurotoxin injections. Most participants with spasticity had prior stroke diagnosis (68%, 11 of 17), with one participant also having spinal stenosis. There were no documented neurological conditions in the medical record that were likely to have caused spasticity for six participants who received a spasticity diagnosis (35%, six of 17). Notably, among the one third of participants with history of stroke (16 of 49), one half had comorbid spasticity and UI (eight of 16), compared to 18% of participants without stroke history who had comorbid spasticity and UI (six of 33; relative risk [RR] = 4.1; 95% confidence interval [CI] [1.7, 10]; p = 0.001).
Most participants had some level of UI recorded (74%, 36 of 49). Existing conditions that could be related to the presence of UI include the following, grouped by disorder: cerebrovascular (44.4%, 16 of 36), dementia (44.4%, 16 of 36), prostate disorder (38.9%, 14 of 36), diabetes (36.1%, 13 of 36), Parkinson's disease (22.2%, eight of 36), CNS trauma (5.6%, two of 36), and urinary tract infection (2.8%, one of 36).
Comorbid Spasticity and Urinary Incontinence
The prevalence of comorbid UI and spasticity was 29% (14 of 49). UI was slightly more prevalent in participants with spasticity (82%, 14 of 17) compared to participants without spasticity (69%, 22 of 32), but this difference was not significant (RR = 1.2; 95% CI [0.82, 1.62]; p = 0.50). More than one third of participants with spasticity had severe UI (38%, six of 16), compared to 9% of participants without spasticity (three of 27; RR = 3.4; 95% CI [1.0, 11.7]; p = 0.06), but this difference did not reach statistical significance. Participants with comorbid spasticity and UI had Modified Ashworth ratings of 1+ (29%, four of 14), 2 (43%, six of 14), 3 (7%, one of 14), and 4 (21%, three of 14). Most participants with lower limb spasticity also had UI (89%, eight of nine) (Figure 2). More than one half of participants with lower limb spasticity had severe UI (five of nine), compared to only 10% of participants without lower limb spasticity (three of 34; RR = 5.5; 95% CI [1.9, 15.9]; p = 0.006).
(A) Activities of daily living (ADL) dependency scores in participants with versus without comorbid spasticity and urinary incontinence. A higher dependency score indicates greater need for assistance in daily tasks. (B) Health-related quality of life in participants with versus without comorbid spasticity and urinary incontinence. A lower EQ-5D utility index indicates a lower quality of life. Triangles denote participants with lower limb spasticity.
Activities of Daily Living
ADL dependency score was significantly worse for participants with both spasticity and UI compared to other participants (i.e., those with only spasticity, with only UI, or without either condition; 4.9, 95% CI [1.6, 8]; p = 0.003) (Figure 2; Table 2). Participants with comorbid spasticity and UI had significantly worse scores on ADL domains of bed mobility (0.5, 95% CI [0.1, 0.9], p = 0.021), transfer (0.6, 95% CI [0.1, 1.1], p = 0.020), locomotion (1.0, 95% CI [0.2, 1.7], p = 0.019), dressing (0.7, 95% CI [0.2, 1.2], p = 0.005), toilet use (0.6, 95% CI [0.1, 1.1], p = 0.018), and personal hygiene (0.9, 95% CI [0.3, 1.4], p = 0.001).
Activities of Daily Living (ADL) Dependency Domains and Health-Related Quality of Life in Participants With Versus Without Comorbid Spasticity and Urinary Incontinence (UI)
Presence of UI was independently associated with greater odds of having a worse ADL dependency score (odds ratio [OR] = 4.7, 95% CI [1.3, 17.1]; p = 0.02). Spasticity presence was associated with greater odds of having a worse ADL dependency score, but this association did not reach statistical significance (OR = 2.6, 95% CI [0.9, 7.3]; p = 0.07). There was no interaction between spasticity and UI on ADL dependency score (p = 0.11).
Health-Related Quality of Life
Participants with spasticity and UI had lower EQ-5D index values (−0.17, 95% CI [–0.33, 0], p = 0.044) (Figure 2) and worse EQ-VAS (−12.2, 95% CI [−25.1, −0.1]; p = 0.049) compared to participants without comorbid conditions. Spasticity presence was independently associated with 3.3-fold greater odds of having a worse EQ-5D index value (OR = 3.3, 95% CI [0.9, 11.5], p = 0.07), but this association did not reach statistical significance. The presence of UI was not independently associated with having a worse EQ-5D index value (p = 0.97).
The results of the current study suggest comorbidity of spasticity and UI is common in the long-term care setting, impacting approximately one of three residents. The potential negative association of this comorbidity is notable because of the markedly increased dependency in ADL and worse health-related QoL for participants with spasticity and UI. Although the consequences of spasticity (Gill et al., 2020; Meijer et al., 2017) and UI (Busby-Whitehead et al., 2015) are separately described, this is the first study to evaluate the prevalence of their comorbidity in this setting and the differences in ADL dependency and QoL in residents with spasticity and UI compared to those without comorbid conditions.
Spasticity and UI can arise secondary to common neurological disorders and CNS injuries, such as stroke, SCI, and TBI (Chua et al., 2003; Jensen et al., 2013; Mehdi et al., 2013; Meng et al., 2010; Sommerfeld et al., 2004). Both conditions also improve with treatments for overactive musculature, such as onabotulinumtoxinA (Barnes, 2003; Burchiel & Hsu, 2001; Nanninga et al., 1989; Schreiber et al., 2009; Watanabe et al., 1997). Notably, lower limb spasticity is associated with bladder dysfunction (Bushman et al., 1993; Meng et al., 2010; Nanninga et al., 1989). Intrathecal baclofen, a muscle relaxant FDA-approved for spasticity but not indicated for UI, improves both lower limb spasticity and bladder dysfunction in people with both conditions (Bushman et al., 1993; Mertens et al., 1995; Nanninga et al., 1989; Schreiber et al., 2009; Talalla et al., 1990). In the current study, all but one participant with lower limb spasticity also had UI documented. A common mechanism of lower limb spasticity and UI has been proposed that involves motor neuron excitability of the external urethral sphincter, resulting in involuntary contraction and incomplete voiding, or inappropriate activation of central reflex pathways involved in lower limb muscle activation and micturition (Bushman et al., 1993; Meng et al., 2010; Nanninga et al., 1989). Treatments for lower limb spasticity may therefore address bladder dysfunction by targeting an underlying common pathway in muscle activity.
Although UI and spasticity are highly prevalent in long-term care residents (Gill et al., 2020; Meijer et al., 2017; Ouslander et al., 1982), these conditions are often not diagnosed (Gill et al., 2020; Lukacz et al., 2017; Minassian et al., 2012; Zürcher et al., 2011). Without adequate recognition, both conditions are therefore frequently left untreated, despite available and effective interventions (Gill et al., 2020; Lukacz et al., 2017; Meijer et al., 2017; Orasanu & Mahajan, 2013; Rekand, 2010). A barrier to diagnosing spasticity is lack of familiarity with the condition among care providers not specifically trained in movement disorders (Sayce et al., 2016). A challenge for UI management is also insufficient knowledge about the condition among care staff (Zürcher et al., 2011). Spasticity and UI are often overlooked due to prioritization of more severe comorbidities associated with underlying neurological impairment (Sayce et al., 2016). Efforts to improve recognition of spasticity and UI and treat residents affected by the negative effects of their comorbidity should emphasize an interdisciplinary approach. Collaborative care among nursing staff, physical and occupational therapists, and clinicians is needed to best understand the complex conditions of residents and subsequently enhance the quality of care. Shared etiology, treatments, and consequences of spasticity and UI warrant further investigation into their comorbidity in the long-term care setting to improve detection and outcomes for these common, treatable conditions.
There are limitations to the current study. This single-center investigation, with a modest sample size, was conducted in a Veterans home, which limits generalizability as the predominantly male cohort does not reflect the general nursing home population. Enrollment in this setting is challenging due in part to most residents being unable to make their own medical decisions and subsequent reliance on proxy consent (Magaziner et al., 2000). Based on prior experience with low proxy consent rates by mail, researchers in this study also approached available MDMs at the facility for resident participation, which approximately doubled the consent rate obtained from a prior study (Turchan, 2016) (14%, eight of 57) compared to this investigation (27%, 19 of 70). Despite this increased enrollment, selection bias is noted as a limitation. The current study also acknowledges the limitations that arise in generalizing the presence of incontinence by solely relying on the MDS. The MDS presents an overview of resident conditions, and currently does not distinguish among the types of incontinence. In addition, a resident with ADL deficits and healthy bladder function may be described as incontinent if help getting to the bathroom is not available. The incontinence and spasticity treatments this study discusses (i.e., intrathecal baclofen and onabotulinumtoxinA), as well as implications in ADL functioning, refer to general UI as noted in the MDS, and therefore may not be suitable for other, more specific types of incontinence.
The results of the current study suggest that spasticity and UI are common comorbidities in the long-term care setting that are associated with more dependence in ADL and worse QoL. Further research across multiple types of long-term care settings is warranted to validate these results and to investigate additional comorbidities of spasticity and UI to refine diagnostic criteria and improve detection for residents who are affected by these treatable conditions.
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|Characteristic||Participants, n (%)|
|All (N = 49)||Comorbid Spasticity and UI||Spasticity Without UI||UI Without Spasticity||No Spasticity or UI|
|n (%)||14 (29)||3 (6)||22 (45)||10 (20)|
| Male||39 (80)||9 (64)||3 (100)||17 (77)||10 (100)|
| Female||10 (20)||5 (36)||0 (0)||5 (23)||0 (0)|
|Mean (SD) (Range)|
|Age (years)||78.2 (9.02) (56 to 96.4)||77.2 (10.3) (59 to 96.4)||75.6 (8.39) (70.2 to 85.3)||79 (8.07) (64 to 92.7)||78.7 (10.3) (61.5 to 90.5)|
|ADL dependency scorea||16.6 (5.7) (5 to 27)||20.1 (5.22) (6 to 27)||11 (6.24) (6 to 18)||16.6 (5.03) (5 to 24)||13.5 (5.3) (6 to 20)|
Activities of Daily Living (ADL) Dependency Domains and Health-Related Quality of Life in Participants With Versus Without Comorbid Spasticity and Urinary Incontinence (UI)
|Variable||Mean (SD) (Range)||Bootstrapped With 10,000 Replications||p Valueb|
|Comorbid Spasticity and UI|
|Noa (n = 35)||Yes (n = 14)||Mean Difference [95% CI]||p Value|
|ADL dependency score||15.2 (5.4) (5 to 24)||20.1 (5.2) (6 to 27)||4.9 [1.6, 8]||0.003||0.014|
|Bed mobility||2.3 (0.9) (1 to 3)||2.9 (0.5) (1 to 3)||0.5 [0.1, 0.9]||0.021||0.030|
|Transfer||2.4 (1) (0 to 4)||3 (0.7) (1 to 4)||0.6 [0.1, 1.1]||0.020||0.030|
|Locomotion||1.8 (1.3) (0 to 4)||2.8 (1.3) (0 to 4)||1 [0.2, 1.7]||0.019||0.030|
|Dressing||2.5 (0.8) (1 to 4)||3.2 (0.8) (1 to 4)||0.7 [0.2, 1.2]||0.005||0.017|
|Eating||1.2 (0.8) (0 to 4)||1.9 (1.2) (1 to 4)||0.6 [0, 1.3]||0.064||0.064|
|Toilet use||2.5 (0.9) (1 to 4)||3.1 (0.8) (1 to 4)||0.6 [0.1, 1.1]||0.018||0.030|
|Personal hygiene||2.4 (1) (1 to 4)||3.3 (0.8) (1 to 4)||0.9 [0.3, 1.4]||0.001||0.013|
|EQ-5D utility index||0.55 (0.26) (0.178 to 1)||0.38 (0.28) (−0.026 to 0.853)||−0.17 [–0.33, 0]||0.044||0.054|
|EQ-VAS||55.9 (22.5) (10 to 100)||43.6 (19.7) (5 to 78)||−12.2 [−25.1, −0.1]||0.049||0.054|
Spasticity-Related ICD 9/10 Codes
|Spasticity ICD 9 Codes||Spasticity ICD 10 Codes|
|336.9: Spinal cord disease NOS||G81.91: Hemiplegia, unspecified affecting right dominant side|
|342.9: Unspecified hemiplegia and hemiparesis affecting unspecified side||G81.92: Hemiplegia, unspecified affecting left dominant side|
|342.91: Unspecified hemiplegia and hemiparesis affecting dominant side||G82.20: Paraplegia, unspecified|
|344.1: Paraplegia NOS||G95.9: Disease of spinal cord, unspecified|
|438.2: Hemiplegia affecting unspecified side||I69.951: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side|
|438.21: Hemiplegia affecting dominant side||I69.952: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side|
|438.22: Hemiplegia affecting non-dominant side||I69.953: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side|
|721.1: Cervical spondylosis with myelopathy||I69.954: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side|
|M47.12: Other spondylosis with myelopathy, cervical region|
Urinary Incontinence-Related ICD9/10 Codes
|Urinary Incontinence ICD 9 Codes||Urinary Incontinence ICD 10 Codes|
|307.7: Encopresis||F98.1: Encopresis not due to a substance or known physiological condition|
|596.51: Hypertonicity of bladder||N31.8: Other neuromuscular dysfunction of bladder|
|596.52: Low bladder compliance||N31.9: Neuromuscular dysfunction of bladder, unspecified|
|596.59: Other functional disorder of bladder||N32.81: Overactive bladder|
|599.81: Urethral hypermobility||N36.41: Hypermobility of urethra|
|599.82: Intrinsic (urethral) sphincter deficiency (ISD)||N36.42: Intrinsic sphincter deficiency (ISD)|
|599.83: Urethral instability||N36.8: Other specified disorders of urethra|
|625.6: Stress incontinence, female||N39.3: Stress incontinence (male) (female)|
|788.3: Urinary incontinence, unspecified||N39.4: Other specified urinary incontinence|
|788.31: Urge incontinence||N39.41: Urge incontinence|
|788.32: Stress incontinence, male||N39.42: Incontinence without sensory awareness|
|788.33: Mixed incontinence, male and female||N39.43: Post-void dribbling|
|788.34: Incontinence without sensory awareness||N39.45: Continuous leakage|
|788.35: Post-void dribbling||N39.46: Mixed incontinence|
|788.37: Continuous leakage||N39.49: Other specified urinary incontinence|
|788.38: Overflow incontinence||N39.490: Overflow incontinence|
|788.39: Other urinary incontinence||N39.492: Postural (urinary) incontinence|
|788.91: Functional urinary incontinence||N39.498: Other specified urinary incontinence|
|R32: Unspecified urinary incontinence|
|R39.81: Functional urinary incontinence|