Abstract
Background
Urinary incontinence is a prevalent condition in the elderly that is the spontaneous leakage of urine. It is an age-related problem and increases especially in people aged above 65 years. It can cause many psychological, behavioral, biological, economic and social effects. The treatment of urinary incontinence can reduce morbidity and mortality. Thus, this study aimed to determine the effects of variables including age, ethnicity, gender, education, marital status, body weight, blood elements and nutritional parameters on urinary incontinence among the Malaysian elderly.
Methods
The study was on 2322 non-institutionalized Malaysian elderly. The hierarchy logistic regression analysis was applied to estimate the risk of independent variables for urinary incontinence among respondents.
Results
The findings indicated that approximately 3.80% of subjects had urinary incontinence. In addition, constipation was found a significant factor that increased the risk of urinary incontinence in samples (p=0.006; OR=3.77). The increase in dietary monounsaturated fat (p=0.038; OR=0.59) and plasma triglyceride levels (p=0.029; OR=0.56) significantly reduced the risk of incontinence in subjects. Many of suspected variables including socio-demographic factors, diseases, nutritional minerals, blood components and body weight were non-relevant factors to urinary incontinence in respondents.
Conclusions
Constipation increased the risk of urinary incontinence in subjects, and increase in dietary monounsaturated fat and plasma triglyceride levels decreased the risk.
Key words: Constipation, elderly, incontinence, triglycerides, monounsaturated fat
Introduction
Urinary incontinence is a prevalent condition in the elderly (1, 2). It occurs when there is inability to keep urine from leaking out (1, 3). The prevalence of urinary incontinence is 2% to 58% (3) depending on research population and definitions used (2). The incidence of problem increases with age (1, 3), hence, it is a considerable public health concern for people who are over 65 years old (1). Urinary incontinence has been reported in more than one third of women and 3-11% of men aged 65 years and above. Its prevalence in the elderly varies from 30% to 50% depending on age (4). In Malaysia, the prevalence of urinary incontinence has been reported between 9% to 9.9% (5). Many countries including Malaysia are aging rapidly (6) and the elderly population in Malaysia is expected to be 9.8% of the overall Malaysian population by year 2020 (7), which can enhance the number of older adults with urinary incontinence.
Urinary incontinence is due to anatomical and functional deficits (8) including inappropriately functioning lower urinary tract, physical problems, cognitive decline (9), functional impairment comorbidities, and medications (4, 10). Several types of urinary incontinence are enuresis, stress urinary incontinence, urgency urinary incontinence, continues urinary incontinence, insensible urinary incontinence, post-prostatectomy urinary incontinence, and mixed urinary incontinence (1, 3).
The most common type of urinary incontinence is urgency urinary incontinence in both elderly men and women (1). The most common reasons of age-related urinary incontinence in men and women are prostate hypertrophy and atrophic urethral mucosa, respectively (3). It remains often untreated in the elderly because of undertaking the condition as a part of normal ageing (4).
Urinary incontinence has great impacts on health, institutionalization, and mortality (1). It leads to dependency, social isolation, low mobility, caregivers pressure, avoiding social gathering, diminished interpersonal relationships (4), and reduced quality of life (1). With the concern to the effects of urinary incontinence on wellbeing, self-esteem, and social functioning (2) as well as its various social, physical (urinary tract infection, perineum infection and perineal skin irritation), and psychological (anger, shame, guilt, anxiety, depression, embarrassment and low self-esteem) consequences (4, 8); this study attempts to identify factors influencing this issue for managing the problem in the elderly.
Material and methods
The project (Project Code: NN-060-2013) was a heterogeneous survey entitled “TUA-Neuroprotective Model for Healthy Longevity among the Malaysian Elderly” and carried out in co-operation with the Universiti Kebangsaan Malaysia (UKM), and the Malaysian Research Institute of Aging, Universiti Putra Malaysia (UPM). The approval and permission for conducting the study were received from the Ethical Committee of the Universiti Kebangsaan Malaysia (UKM).
This research as a part of above project recruited 2322 subjects who were the Malaysian elderly aged 60 years and above residing in non-institutional places. Samples were from different ethnic groups involving Malays, Chinese, Indians and others. The elderly who were living in institutions and bedridden, were excluded. Then, respondents were gathered at community halls or centers for interviewing and health screening. The written consent was obtained before the interview. The trained fieldworkers conducted a face-to-face interview. This project evaluated the effects of variables including body weight, socio-demographic factors, chronic diseases, nutritional status, and blood components on urinary incontinence in the Malaysian elderly (Table 2). Questionnaires were used to collect data about socio-demographic factors, urinary incontinence and nutritional status. Age was dichotomized into (1) “less than 75 years” and (2) “75 years and above”. The report of urinary incontinence in subjects was based on physician approval and/or taking any medication. Subjects were coded as no having incontinence (0) and having incontinence (1). The evaluation of nutritional dietary intake of compounds was by History Questionnaires (DHQ) and Nutritionist Pro 3. Venous blood was taken from samples for testing the effects of blood levels of albumins, glucose, triglycerides, and cholesterols on the risk of urinary incontinence among the Malaysian elderly subjects. The obtained data were classified into two groups to facilitate regression analysis.
Table 2.
The list of factors assessed for the presence of correlation with urinary incontinence
| Sociodemographic Factors | |||
| Age | Gender | Marital status | Ethnicity |
| Education | Bodyweight | Sleep | |
| Food Components | |||
| Energy | Folate | Selenium | Magnesium |
| Vit C | Cobalamin | Sodium | Zinc |
| Vit D | Biotin | Isoleucine | Manganese |
| Vit E | Riboflavin | Leucine | Protein |
| Vit A | Chrome | Lysine | Fat (mono, poly, saturated) |
| Vit K | Threonine | Valine | Carbohydrates |
| Fiber | Cysteine | Histidine | Alcohol |
| Beta Carotene | Phenylalanine | Alpha-Tocopherol | Cholesterol |
| Tryptophan | Tyrosine | Thiamin | Linoleic |
| Methionine | Copper | Pantothenic Acid | EPA |
| Pyridoxine | Molybdenum | Phosphorous | DHA |
| Niacin | Iron | Sugar | |
| Diseases | |||
| Constipation | Thyroid Problem | Chewing Problem | Joint Pain |
| Hemorrhoid | Cancer | Appetite loss | Cognitive Decline |
| Gastric-Ulcer problem | Vision-Hearing Loss | Stroke | Cataract-Glaucoma |
| Renal Failure | Dry Cough | Hypercholesterolemia | Tiredness |
| Lung Problems | Bone Fracture | Diabetes | Hypertension |
| Heart Problem | |||
| Blood Components | |||
| Hemoglobin | Blood Glucose | Blood Cholesterol | Blood Triglycerides |
| Blood Albumin |
|||
Statistical analysis
A two-step hierarchical binary logistic regression model using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA) was used to test the effects of demographic factors, body weight, nutritional status and blood components on urinary incontinence. Prior to regression analyses, correlation tests were examined to determine the existence of associations between a dependent variable and covariates. Only significant correlations were considered in regression analysis. The first step of analysis assessed the effects of diseases on the risk of urinary incontinence. The second model was built on Model 1 by adding the plasma levels of triglycerides and albumins as well as the dietary level of monounsaturated fat. Odds ratios (OR) with 95% confidence intervals (95% CI) were computed. The critical level for rejection of the null hypothesis was considered to be a p value of 5%, two-tailed.
Results
Various analyses were run on data collected from 2322 respondents who were Malaysian elderly and noninstitutionalized. The prevalence of urinary incontinence in subjects was approximately 3.80% (95% CI: 3.09-4.65) (Table 1). The factors assessed in the project have been listed in Table 2. In addition, the percentage of urinary incontinence in samples with regard to the factors that have p value less than 0.1 has been summarized in table 3.1 and table 3.2. The results in table 3.1 showed that the prevalence of urinary incontinence in the age groups of (1) less than 75 years and (2) 75 years and above was 3.68% and 4.22%, respectively. It was found that the prevalence of urinary incontinence in females (3.97%) was higher than males (3.59%). Non-married subjects (4.07%) displayed a greater rate of urinary incontinence compared to married subjects (3.66%). The percentage of urinary incontinence in educated respondents (4.04%) was higher than non-educated ones (2.85%). Among all samples, non-Malays (4.57%) had a higher rate of urinary incontinence than Malays (3.32%). Furthermore, the percentage of incontinence at the presence of diet compounds, and blood components has been summarized in table 3.2.
Table 1.
Prevalence of urinary incontinence among 2332 Malaysian elderly
| Character | n | n (%) | 95% CI |
|---|---|---|---|
| Urinary Incontinence | |||
| Yes | 88 | 3.80 | 3.09-4.65 |
| No | 2234 | 96.2 | 95.35-96.91 |
| Counted=2322 |
Table 3.1.
Prevalence of urinary incontinence and associations with factors
| Whole | n | n % | 95% CI | χ2 | p value | |
|---|---|---|---|---|---|---|
| Age Group | ||||||
| Less than 75 years | 1848 | 68 | 3.68 | 2.91-4.64 | 0.301 | 0.583 |
| 75 years and above | 474 | 20 | 4.22 | 2.75-6.43 | ||
| Gender | ||||||
| Males | 1114 | 40 | 3.59 | 2.65-4.85 | 0.233 | 0.629 |
| Females | 1208 | 48 | 3.97 | 3.01-5.22 | ||
| Marital status | ||||||
| Married | 1585 | 58 | 3.66 | 2.84-4.7 | 0.233 | 0.629 |
| Non-Married | 737 | 30 | 4.07 | 2.87-5.75 | ||
| Ethnicity | ||||||
| Malays | 1447 | 48 | 3.32 | 2.51-4.37 | 2.352 | 0.125 |
| Non-Malays | 875 | 40 | 4.57 | 3.37-6.16 | ||
| Education | ||||||
| No | 492 | 14 | 2.85 | 1.71-4.72 | 1.527 | 0.217 |
| Yes | 1830 | 74 | 4.04 | 3.23-5.04 | ||
| LDL Cholesterol | ||||||
| 0-3.2 | 895 | 45 | 5.03 | 3.78-6.66 | 2.924 | 0.087 |
| >3.2-11.10 | 883 | 30 | 3.4 | 2.39-4.81 | ||
| Blood Triglycerides | ||||||
| 1.3 mg or less | 916 | 49 | 5.35 | 4.07-7 | 5.958 | 0.015 |
| >1.3 mg | 861 | 26 | 3.02 | 2.07-4.39 | ||
| Blood Albumin | ||||||
| 31-43 g | 1113 | 56 | 5.03 | 3.89-6.48 | 4.977 | 0.026 |
| >43-64 g | 669 | 19 | 2.84 | 1.83-4.39 | ||
| Total cholesterol/HDL | ||||||
| 1.70-4 | 969 | 50 | 5.16 | 3.94-6.74 | 4.790 | 0.029 |
| >4-12.10 | 814 | 25 | 3.07 | 2.09-4.49 | ||
| Fat | ||||||
| 50 g or less | 1084 | 33 | 3.04 | 2.17-4.24 | 2.918 | 0.088 |
| >50 g | 1106 | 49 | 4.43 | 3.37-5.81 | ||
| Oleic | ||||||
| 0-2 | 1685 | 70 | 4.15 | 3.3-5.21 | 3.458 | 0.063 |
| >2-33.68 | 507 | 12 | 2.37 | 1.36-4.1 | ||
| Monounsaturated fat | ||||||
| 0.01-7.2 | 1081 | 52 | 4.81 | 3.69-6.25 | 6.775 | 0.009 |
| >7.2-47.93 |
1111 |
30 |
2.7 |
1.9-3.83 |
Significant at the 0.05 level using the chi-square test
Table 3.2.
Prevalence of urinary incontinence and associations with factors
| Whole | n | n % | 95% CI | χ2 | p value | |
|---|---|---|---|---|---|---|
| Cognition | ||||||
| Problem | 1570 | 52 | 3.31 | 2.53-4.32 | 3.265 | 0.071 |
| Normal | 719 | 35 | 4.87 | 3.52-6.7 | ||
| Cataract-glaucoma | ||||||
| No | 2174 | 78 | 3.59 | 2.89-4.46 | 3.816 | 0.051 |
| Yes | 148 | 10 | 6.76 | 3.71-11.99 | ||
| Kidney disease | ||||||
| No | 2290 | 85 | 3.71 | 3.01-4.56 | 2.776 | 0.096 |
| Yes | 32 | 3 | 9.38 | 3.24-24.22 | ||
| Stroke | ||||||
| No | 2293 | 85 | 3.71 | 3.01-4.56 | NA | 0.095 |
| Yes | 29 | 3 | 10.34 | 3.58-26.38 | ||
| Tiredness | ||||||
| No | 2206 | 79 | 3.58 | 2.88-4.44 | NA | 0.039 |
| Yes | 116 | 9 | 7.76 | 4.14-14.09 | ||
| Constipation | ||||||
| No | 2269 | 79 | 3.48 | 2.8-4.32 | NA | <0.001 |
| Yes | 53 | 9 | 16.98 | 9.2-29.22 | ||
| Gastric-Ulcer Problem | ||||||
| No | 2117 | 71 | 3.35 | 2.66-4.2 | 12.503 | <0.001 |
| Yes | 205 | 17 | 8.29 | 5.24-12.87 | ||
| Vision-hearing loss | ||||||
| No | 2208 | 78 | 3.53 | 2.84-4.38 | NA | 0.010 |
| Yes | 114 | 10 | 8.77 | 4.83-15.39 | ||
| Joint pain | ||||||
| No | 2077 | 70 | 3.37 | 2.68-4.24 | 9.505 | 0.002 |
| Yes |
245 |
18 |
7.35 |
4.7-11.32 |
Significant at the 0.05 level using the chi-square test; CI: Confidence Interval; n: Number of individuals; x2: value of chi-square test
The bivariate analysis established the association between urinary incontinence and each of variables by chi-square tests. The results showed a significant association between the risk of urinary incontinence and variables including tiredness (χ2=NA, p=0.039), constipation (χ2=NA, p<0.001), gastriculcer (χ2=12.50, p<0.001), joint pain (χ2=9.51, p=0.002), vision-hearing loss (χ2=NA, p=0.010), dietary monounsaturated fats (χ2=6.78, p=0.009), plasma albumins (χ2=4.98, p=0.026), and plasma triglyceride levels (χ2=5.96, p=0.015) (Table 3.1 and 3.2).
As this study aimed to predict the effects of sociodemographic factors, blood components, and nutritional status on the risk of urinary incontinence, a two-step hierarchical regression analysis was used. The findings indicated that constipation (p=0.006) significantly enhanced the risk of urinary incontinence in respondents (p<0.01). Furthermore, increase in plasma triglyceride levels (p=0.029) and dietary monounsaturated fat (p=0.038) significantly reduced the risk of urinary incontinence. Tiredness, gastric-ulcer, joint pain, vision-hearing loss, and serum albumins did not have any significant effect on urinary incontinence (p>0.05). The results have been summarized in Table 4.
Table 4.
Prevalence of urinary incontinence and associations derived by logistic regression analysis
| Variables | Model 1 |
Model 2 |
||||
|---|---|---|---|---|---|---|
| B | SE | OR | B | SE | OR | |
| Tiredness | 0.397 | 0.468 | 1.49 | 0.356 | 0.466 | 1.43 |
| Constipation | 1.355* | 0.469 | 3.88 | 1.327* | 0.478 | 3.77 |
| Gastric-Ulcer Problem | 0.628 | 0.348 | 1.87 | 0.662 | 0.355 | 1.94 |
| Vision-hearing loss | 0.756 | 0.404 | 2.13 | 0.797 | 0.414 | 2.22 |
| Joint Pain | 0.510 | 0.325 | 1.67 | 0.507 | 0.329 | 1.66 |
| Plasma Triglycerides | -0.576* | 0.263 | 0.56 | |||
| Plasma Albumins | -0.523 | 0.289 | 0.59 | |||
| Monounsaturated fats |
-0.528* |
0.255 |
0.59 |
|||
p<0.05
Discussion
Because of longer life expectancy and health behaviors, the number of older adults who suffer from urinary incontinence is on the rise worldwide (11); therefore, further studies are required to identify the risk factors of urinary incontinence and to know how to manage it. Such research may help to prevent or delay the rate of disease and its consequences in the elderly. The prevalence was found 3.80% in the elderly of Malaysia, which was less than the other studies those reported range between 9-9.9% (7, 12, 13). The prevalence of urinary incontinence in Malaysia has been reported less than other countries. It is likely an underestimate of actual situation as the elderly individuals may not reveal their health problem (7) or may consider it as a normal part of ageing.
This study evaluated the effects of some socio-demographic factors, nutritional compounds, and blood components on the risk of urinary incontinence in the Malaysian elderly. According to the final model, constipation, and increase in dietary monounsaturated fats, and plasma triglyceride levels were significant predictors for the risk of urinary incontinence in subjects.
Constipation prominently increased the risk of urinary incontinence in subjects the same as previous reports (8, 14., 15., 16.). It seems that constipation causes anatomical changes (15) and urethral angle change (8), which result in urinary incontinence because of overactive bladder, urine retention, and sphincter control loss. It has been reported that the obstruction of outflow due to a compressed stool and severe constipation can cause transient incontinence. On the other hand, the treatment of urinary incontinence by eliminating fluid intake and/or using anticholinergic drugs (17) can exacerbate the risk of constipation (18), which in turn worsen urinary incontinence.
Despite the non-significant effect of age on urinary incontinence in our study, previous reports showed that ageing can enhance the risk. They claimed that advancing age changes the anatomy and patho-physiology of urinary system, which in turn can lead to urinary incontinence. It seems that ageing may increase need for more frequent bladder emptying on urinary system because of the reduced size of the urinary bladder, decreased bladder volume and early detrusor contractions (7). Such disparity may happen due to the effects of confounding factors. The findings showed that high dietary monounsaturated fat and increase in plasma triglyceride levels eliminated the risk of urinary incontinence in the Malaysian elderly. Triglycerides are the most common form of fat in the body (19). A specific and direct role of plasma triglycerides in the control of urinary incontinence is not yet well determined, however, it seems that increase in plasma triglyceride levels provides more access to energy for physical activities and muscle fibers (20), which in turn reduce urinary incontinence via the enhancement of the urinary bladder and detrusor activities.
The triglyceride pathway plays a critical role in lipid peroxidation in the detrusor mitochondria (21) and fatty acid delivery to the detrusor muscle by mitochondria (20). Spontaneous activities in the detrusor smooth muscle are strongly associated with mitochondrial reactions (22). The age-related accumulation of reactive oxygen species (ROS) also affects the contractility of detrusor (21) through damaging mitochondria (23). Thus, increase in plasma triglyceride levels probably reduces these deficits and the risk of urinary incontinence. Furthermore, the reductive effects of monounsaturated fats on urinary incontinence in the elderly can be related to their positive effects on inflammation, mental health, and cognitive ageing (24). The possible effects of such fats on inflammation, serum C-reactive protein levels and vascular changes improve endothelial function in the bladder, and the detrusor, which reduces urinary incontinence and urologic symptoms (25). These fats also lead to less anger and irritability (26), which are able to improve cognitive ability in the elderly and in turn reduce urinary incontinence. Such fats as good fats can reduce the risk of urinary incontinence by the prevention of chronic diseases such as stroke, diabetes mellitus, and coronary heart disease (27), as well as the activation of nerve function (28). Furthermore, the regulatory effect of dietary monounsaturated fat on plasma hormone levels can lead to a better function of the bladder and the urethra intake (29). On the contrary, there are some prior reports indicating increasing effects (29) or no influences (25, 30) of such fats of such fats on urinary incontinence. In addition, urinary incontinence was not found relevant to energy level, which was in contrast to a research by Maserejian and colleagues (25). Thus, the results should be interpreted with caution (31) and additional studies in humans and proper animal models are needed to gain a better understanding about the effects of fats on urinary incontinence.
Sometimes urinary incontinence is just one of the serious presentations of medical disorders such as stroke or systemic infection. Factors such as diabetes mellitus, and alcohol consumption have been reported sometimes as the factors effective on urinary incontinence (4), while these factors and sociodemographic factors were ineffective in our research. However, many factors including eating, drinking and smoking habits and home environment such as lighting, staircase, location of bathroom, distance of bed to bathroom, and living arrangements should be assessed in the elderly in order to test their effects on urinary incontinence. Besides, medications such as diuretics, food substances like caffeine and medical problems such as hernias, urethritis, urethra stricture, local infections, distended bladder, abdominal and pelvic masses as well as nutritional, hydrational and anemic status should be evaluated in the elderly who are with urinary incontinence (4).
Despite several reports indicating correlation between ethnicity (32), gender and age (7, 33) with urinary incontinence, our study found nothing, which is likely because of the interference of confounding factors on the risk of urinary incontinence. While ethnicity can affect health through cultural factors, migration, education, health beliefs and socio-economic status (34), our findings did not show any correlation between urinary incontinence and ethnicity.
The preference of a gender as female (33) or male (7) to increase the risk of urinary incontinence varies among reports. The difference in lifestyles, co-morbidities and medications probably cause such disparity (35). Even though, some reports indicate the positive effects of testosterone (36), and estrogen (37) on urinary system, hormone therapy in the elderly is controversial in men (36) and women (10, 37, 38).
The difference in the rate of urinary incontinence among different groups such as educated and non-educated ones may refer to the misconception that the disease is a part of the normal ageing process (4) or social concerns that they do not like to reveal their health problem (7); therefore, it remains untreated among those groups (4).
However, urinary incontinence is a common problem in the elderly that is associated with self-esteem and quality of life. Meanwhile, urine control is in relation to social, economic, physical, and psychological circumstances. Thus, the improvement of knowledge and methods including bladder re-training, behavioral modifications, prompted voiding, pelvic floor muscle exercises (Kegel exercise) and lifestyle changes such as caffeine restriction can help to reduce the problem. For example, Kegel exercise can effectively control about 50% of patients with stress urinary incontinence (1, 4).
Conclusion
It was concluded that constipation strongly increased the risk of urinary incontinence in subjects. In addition, increase in plasma triglyceride levels and dietary monounsaturated fat reduced the risk of disease. Surprisingly, none of sociodemographic factors showed significant effects on the risk of urinary incontinence in the Malaysian elderly. Further studies are required to improve our knowledge regarding the risk factors of risk factors of urinary incontinence in order to control disease and consequences.
Acknowledgments:
This study was funded through Long Term Research Grant Scheme (LRGS), the Ministry of Education Malaysia under research program entitled TUA-Neuroprotective Model for Health Longevity among Malaysian Elderly (Project No. LRGS/BU/2012/UKM-UKM/K01). Authors gratefully acknowledge the co-operation of all volunteers who participated in this study. At the same time, they wish to acknowledge the financial support from the Ministry of Education. In addition, authors also thank all staff for their efforts in data collection.
Limitations of study
Some limitations confined our study and affected the interpretation of data. One of limits was the cross-sectional design of study, which confined to determine the exact effects of variables on the risk of urinary incontinence. Furthermore, physical and psychological co-morbidities of subjects could limit the appropriate assessment of risk factors for urinary incontinence. However, further investigations are needed to identify the exact causes of risk factors for urinary incontinence in the elderly.
Competing interests:
Authors declare that there is no conflict of interest.
Ethical Standards
The authors declared that the experiments comply with the current laws of the country in which they were performed (Malaysia).
References
- 1.Greer JA, Arya LA, Smith AL. Urinary incontinence: diagnosis and treatment in the elderly. Current Translational Geriatrics and Experimental Gerontology Reports. 2013;2(2):66–75. 10.1007/s13670-013-0037-6 [Google Scholar]
- 2.Teunissen D, van Weel C, Lagro-Janssen T. Urinary incontinence in older people living in the community: examining help-seeking behaviour. British Journal of General Practice. 2005;55(519):776–782. PubMed PMID: 16212853, PMCID 1562332. [PMC free article] [PubMed] [Google Scholar]
- 3.Tong Y-C. Diagnosis and treatment of geriatric urinary incontinence. Incont Pelvic Floor Dysfunct. 2009;3:69–72. [Google Scholar]
- 4.Loh K, Sivalingam N. Urinary incontinence in the elderly population. The Medical journal of Malaysia. 2006;61(4):506–510. PubMed PMID: 17243536. [PubMed] [Google Scholar]
- 5.Yusoff SN, Buja GA, Aged society: The way forward. International Conference on Business and Economics Research, 2013
- 6.Sherina MS, Lekhraj R, Mustaqim A. Functional status of the elderly in a rural community in Malaysia. Malaysian Journal of Public Health Medicine. 2004;4(1):55–58. [Google Scholar]
- 7.Sidik SM. The prevalence of urinary incontinence among the elderly in a rural community in Selangor. The Malaysian journal of medical sciences: MJMS. 2010;17(2):18. [PMC free article] [PubMed] [Google Scholar]
- 8.Bhagwath G. Urinary Incontinence in the Elderly: Pathogenesis an d Management. Journal of Indian Academy of Clinical Medicine. 2001;2:270–275. [Google Scholar]
- 9.Cook K, Sobeski LM, Urinary Incontinence in the Older Adult. PSAP, 2013, 3–20
- 10.Kuchel GA, DuBeau CE, Chapter 30: Urinary Incontinence in the Elderly. Geriatric Nephrology Curriculum, 2009, 1–5
- 11.Fonda D, Benvenuti F, Cottenden A, DuBeau C, Kirshner-Hermanns R, Miller K, Palmer M, Resnick N, et al. Abrams P, et al. Urinary incontinence and bladder dysfunction in older persons. 2nd International Consultation on Incontinence: Recommendations of the International Scientific Committee, 2002, 625–295
- 12.Poi P, Srinivas P, Giants of Geriatrics II–Incontinence. Proceedings of First National Symposium On Gerontology, 1995, 92–97
- 13.Chia Y, Srinivas P, Primary Care in the Elderly. Proceedings of First National Symposium On Gerontology, 1995, 98–110
- 14.Dowling-Castronovo A. Urinary Incontinence Assessment in Older Adults Part I–Transient Urinary Incontinence. Obstetrics & Gynecology. 1985;109(2):277–280. [Google Scholar]
- 15.Kow JK, Carr M, Whytock S. Diagnosis and management of urinary incontinence in residential care. British Columbia Medical Journal. 2013;55(2):96–100. [Google Scholar]
- 16.DeMaagd GA, Davenport TC. Management of urinary incontinence. Pharmacy and Therapeutics. 2012;37(6):345. PubMed PMID: 22876096, PMCID 3411204. [PMC free article] [PubMed] [Google Scholar]
- 17.Goepel M, Kirschner-Hermanns R, Welz-Barth A, Steinwachs K-C, Rübben H. Urinary incontinence in the elderly: part 3 of a series of articles on incontinence. Deutsches Ärzteblatt International. 2010;107(30):531. doi: 10.3238/arztebl.2010.0531. PubMed PMID: 20737059, PMCID 2925344. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Woodward MC, Constipation in older people: pharmacological management issues, 2002
- 19.Birtcher KK, Ballantyne CM. Measurement of Cholesterol^A Patient Perspective. Circulation. 2004;110(11):e296–e297. doi: 10.1161/01.CIR.0000141564.89465.4E. 10.1161/01.CIR.0000141564.89465.4E PubMed PMID: 15364820. [DOI] [PubMed] [Google Scholar]
- 20.Coyle EF. Fat metabolism during exercise. Sports Science Exchange. 1995;8(6):59. [Google Scholar]
- 21.Lin ATL, Yang C, Chen KK, Chang LS. Detrusor mitochondrial lipid peroxidation and superoxide dismutase activity in partial bladder outlet obstruction of rabbits. Neurourology and urodynamics. 2005;24(3):282–287. doi: 10.1002/nau.20109. 10.1002/nau.20109 PubMed PMID: 15791627. [DOI] [PubMed] [Google Scholar]
- 22.Kubota Y, Hashitani H, Fukuta H, Kubota H, Kohri K, Suzuki H. Role of mitochondria in the generation of spontaneous activity in detrusor smooth muscles of the Guinea pig bladder. The Journal of urology. 2003;170(2):628–633. doi: 10.1097/01.ju.0000069428.46133.d5. 10.1097/01.ju.0000069428.46133.d5 PubMed PMID: 12853845. [DOI] [PubMed] [Google Scholar]
- 23.Cui H, Kong Y, Zhang H, Oxidative stress, mitochondrial dysfunction, and aging. Journal of signal transduction, 2011, 1–13 [DOI] [PMC free article] [PubMed]
- 24.Baierle M, Vencato PH, Oldenburg L, Bordignon S, Zibetti M, Trentini CM, Duarte MM, Veit JC, Somacal S, Emanuelli T. Fatty Acid Status and Its Relationship to Cognitive Decline and Homocysteine Levels in the Elderly. Nutrients. 2014;6(9):3624–3640. doi: 10.3390/nu6093624. 10.3390/nu6093624 PubMed PMID: 25221976, PMCID 4179179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Maserejian NN, Giovannucci EL, McVary KT, McGrother C, McKinlay JB, Dietary macronutrient and energy intake and urinary incontinence in women. American journal of epidemiology kwq065, 2010 [DOI] [PMC free article] [PubMed]
- 26.Kien CL, Bunn JY, Tompkins CL, Dumas JA, Crain KI, Ebenstein DB, Koves TR, Muoio DM. Substituting dietary monounsaturated fat for saturated fat is associated with increased daily physical activity and resting energy expenditure and with changes in mood. The American journal of clinical nutrition. 2013;97(4):689–697. doi: 10.3945/ajcn.112.051730. 10.3945/ajcn.112.051730 PubMed PMID: 23446891, PMCID 3607650. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Yaqoob P. Monounsaturated fats and immune function. Brazilian journal of medical and biological research. 1998;31(4):453–465. doi: 10.1590/s0100-879x1998000400001. 10.1590/S0100-879X1998000400001 PubMed PMID: 9698797. [DOI] [PubMed] [Google Scholar]
- 28.Bourre J-M. Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain. Part 2: macronutrients. Journal of Nutrition Health and Aging. 2006;10(5):386. [PubMed] [Google Scholar]
- 29.Dallosso H, Matthews R, McGrother C, Donaldson M. Diet as a risk factor for the development of stress urinary incontinence: a longitudinal study in women. European journal of clinical nutrition. 2004;58(6):920–926. doi: 10.1038/sj.ejcn.1601913. 10.1038/sj.ejcn.1601913 PubMed PMID: 15164113. [DOI] [PubMed] [Google Scholar]
- 30.Maserejian NN, Mcvary KT, Giovannucci EL, Mckinlay JB. Dietary macronutrient intake and lower urinary tract symptoms in women. Annals of epidemiology. 2011;21(6):421–429. doi: 10.1016/j.annepidem.2010.11.014. 10.1016/j.annepidem.2010.11.014 PubMed PMID: 21421330, PMCID 3090524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Kris-Etherton PM. Monounsaturated fatty acids and risk of cardiovascular disease. Circulation. 1999;100(11):1253–1258. doi: 10.1161/01.cir.100.11.1253. 10.1161/01.CIR.100.11.1253 PubMed PMID: 10484550. [DOI] [PubMed] [Google Scholar]
- 32.Thom DH, Van Den Eeden SK, Ragins AI, Wassel-Fyr C, Vittinghof E, Subak LL, Brown JS. Differences in prevalence of urinary incontinence by race/ethnicity. The Journal of urology. 2006;175(1):259–264. doi: 10.1016/S0022-5347(05)00039-X. 10.1016/S0022-5347(05)00039-X PubMed PMID: 16406923, PMCID 1557354. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Santos C, Santos VLCG. Prevalence of urinary incontinence in a random sample of the urban population of Pouso Alegre, Minas Gerais, Brazil. Revista latino-americana de enfermagem. 2010;18(5):903–910. doi: 10.1590/s0104-11692010000500010. 10.1590/S0104-11692010000500010 PubMed PMID: 21120409. [DOI] [PubMed] [Google Scholar]
- 34.Fincham JE, Health policy and ethics, 2011
- 35.Litman HJ, Steers WD, Wei JT, Kupelian V, Link CL, McKinlay JB, Investigators BACHS. Relationship of lifestyle and clinical factors to lower urinary tract symptoms: results from Boston Area Community Health survey. Urology. 2007;70(5):916–921. doi: 10.1016/j.urology.2007.06.1117. 10.1016/j.urology.2007.06.1117 PubMed PMID: 17919693, PMCID 2194647. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Kim SC, Testosterone Deficiency Linked to Lower Urinary Tract Symptoms, 2012
- 37.Robinson D, Cardozo LD. The role of estrogens in female lower urinary tract dysfunction. Urology. 2003;62(4):45–51. doi: 10.1016/s0090-4295(03)00676-9. 10.1016/S0090-4295(03)00676-9 PubMed PMID: 14550837. [DOI] [PubMed] [Google Scholar]
- 38.Jackson RA, Vittinghoff E, Kanaya AM, Miles TP, Resnick HE, Kritchevsky SB, Simonsick EM, Brown JS, Health A, Study BC. Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study. Obstetrics & Gynecology. 2004;104(2):301–307. doi: 10.1097/01.AOG.0000133482.20685.d1. 10.1097/01.AOG.0000133482.20685.d1 [DOI] [PubMed] [Google Scholar]