Abstract
Objective
Our objective was to determine the prevalence of functional disability among older women with urinary incontinence (UI).
Methods
We conducted a secondary analysis of the 2005-06 National Social Life, Health and Aging Project (NSHAP). Daily UI was defined as answering “daily” to the question, “How frequently...have you had difficulty controlling your bladder, including leaking small amounts of urine, leaking when you cough or sneeze, or not being able to make it to the bathroom on time?” We then explored functional status. Women were asked about seven basic activities of daily living (ADLs). Statistical analyses with percentage estimates and 95% confidence intervals (CI) were performed. Logistic regression was performed to assess the association between functional status and daily UI.
Results
In total, 1,412 women were included in our analysis. Daily UI was reported by 177 (12.5%) women. Functional dependence or disability with any ADLs was reported in 62.1% (95% CI 54.2%, 70.1%) of women with daily UI. Among women with daily UI, 23.6% (95% CI 16.8%, 30.5%) reported specific difficulty or dependence with using the toilet signifying functional limitations which may contribute to urine leakage. After adjusting for age category, race/ethnicity, education level, and parity, women with daily UI had 3.31 increased odds of functional difficulty or dependence compared with continent older women.
Conclusion
Over 60% of older women with daily UI reported functional difficulty or dependence and 1/4 of women with daily UI specifically reported difficulty or dependence with using the toilet.
Keywords: activities of daily living, dependence, functional status, mobility, urinary incontinence
INTRODUCTION
Urinary incontinence (UI) is a common condition that can have a profound impact on women's lives. The prevalence of urinary incontinence increases dramatically with age.(1, 2) Incontinence is associated with decreased quality of life, poor self-rated health and depression in older women. (3-5) Incontinence can result from disease-specific processes such as detrusor overactivity or pelvic floor dysfunction. However, incontinence also can result “from physical or cognitive limitations that prevent a person from reaching or using the toilet.”(6) Inability to reach the toilet due to these functional limitations is termed functional UI.(6)
Functional status is commonly measured in community-dwelling adults by assessing the ability to perform activities of daily living (ADLs) without assistance. (7) Functional disability and dependence on other people to perform ADLs is an important predictor in older adults of developing adverse outcomes of aging (long-term nursing home (NH) stay, injurious falls, and death) independent of medical comorbidities and age.(8) Tinetti et al demonstrated that both UI and functional dependence share common risk factors predisposing older adults to both conditions.(8) While we know that UI and functional dependence are inter-related conditions, the burden of disability among women with UI is not well described. Knowledge of the burden of disability specifically related to toileting and the relationship with UI is also not well described. Finally, the prevalence of compromised mobility (which would decrease the ability to reach the toilet without leakage) in women with UI is also unknown.
We propose that UI resulting from or exacerbated by functional limitations and compromised mobility may coexist with etiologies for UI that are specifically related to bladder and/or pelvic floor function. In this work, we used a nationally representative sample of community-dwelling older women to determine the prevalence of functional disability in women with UI. We then estimated the prevalence of older women with UI specifically reporting functional disability related to using the toilet. Our secondary aim was to estimate the prevalence of compromised mobility in older women with UI.
METHODS
We conducted a secondary database analysis of the National Social Life, Health and Aging Project (NSHAP), a cross-sectional cohort of community-dwelling men and women in the United States between the ages of 57-85 years surveyed in 2005-2006.(9) The NSHAP was conducted to examine social networks, overall health, and sexual practices of older adults. Adults were targeted for participation in the NHSAP study if they participated in a prior population-based study, the Health and Retirement Study, of community-dwelling older Americans.(10) The overall survey response rate of the NSHAP was 75.5%. Information in the NSHAP was obtained from a single in-home interview conducted by trained professional interviewers in both English and Spanish using computer-assisted personal interview (CAPI) methods(11). Written exemption for this study was obtained from the Yale University Institutional Review Board as this work involved research of an existing dataset from a public source.
For this analysis, we included all women in the NSHAP (n = 1,510). Women were excluded if they had missing data for questions on incontinence (n=98). Women were categorized as having daily UI if they answered “daily” to the question, “How frequently...have you had difficulty controlling your bladder, including leaking small amounts of urine, leaking when you cough or sneeze, or not being able to make it to the bathroom on time?” Women could answer, daily, weekly, monthly, yearly, or never. UI was categorized in three categories: “daily”, “some” which included women reporting weekly, monthly, or yearly UI, and “none”. These three categories represent increasing frequency of UI.
We then categorized functional status. Women were asked previously validated questions about seven ADLs including walking across a room, walking one block, dressing, bathing, eating, toileting, and getting in and out of bed.(12) Women's status for each ADL was defined as belonging to one of three categories: independent, independent with difficulty if they reported difficulty with performing any of the ADLs but did not require assistance and dependent if they reported inability to perform the ADL without assistance.(13) Overall functional status was defined according to single variable combining the responses of all 7 ADLs. Women were placed into one of three categories for overall functional status: independent, independent with difficulty, and dependent as proposed by Gill et al. (13) Women who could not to perform one or more ADL without assistance were categorized as dependent. Women, who reported difficulty in performing one or more ADLs, without reporting dependence, were categorized as independent with difficulty. Women who were categorized as independent reported no difficulty or dependence in performing any of the seven ADLs.
We also analyzed compromised mobility using multiple measurements. We first examined a timed “Get up and Go” test as this test is a preferred measurement of mobility by the American Geriatric Society.(14) The timed “Get up and Go” test was conducted at the time of the single in-home NSHAP interview. This measurement is the total time it takes a woman to rise from a seated position without using an armrest, walk 3 meters, turn around, return, and sit-down. A total “Get up and Go” test time of more than 12 seconds indicates compromised mobility.(12, 15) Additionally, we analyzed if a woman was observed to walk unsteadily or use an assistive walking device, such as a cane. We also analyzed frequency of physical activity and self-report of falls in the last 12 months.
Demographics including age category (57 to 64 years, 65 to 74 years, and 75 to 85 years), race/ethnicity, education level, self-reported health status relative to peers overall health, parity, body mass index (BMI, kg/m2), number of medical comorbidities and depressive symptoms measured by the modified Center for Epidemiological Studies-Depression (CES-D) scale were examined. The modified CES-D scale is an 11 question screening test for depressive symptoms.(16, 17) Scores for the CES-D range from 0-33 and higher scores indicating more depressive symptoms. The use of the CES-D scale is not intended to be diagnostic for depression. The CES-D is intended to be used as a screening tool with increased CES-D scores indicating more depressive symptoms.(16-18) Self-reported health status questions on the NSHAP comprised two modified questions that have been demonstrated reflect a wide array of more specific health measures and also demonstrated to be a useful indicator of both health and mortality.(12)
Statistical analyses, including descriptive and inferential statistics with percentage estimates and 95% confidence intervals (CI), were performed as appropriate. P-values of <.05 were considered statistically significant. The NSHAP dataset allowed data to be weighted to provide an estimate of population characteristics representative of community-dwelling older Americans aged 57 to 85 years. Survey weights were applied to crude frequency estimates to account for the differential probability of inclusion in the sample. Percentage estimates and 95% CI were reported as weighted frequencies. Model fitting and variance estimates used in the construction of CI account for the stratified and clustered nature of the design to produce unbiased estimates of standard errors.
A logistic regression analysis was then performed to examine the independent relationship between UI and functional disability. Potential confounders were included in the final model based on their significance in univariate analysis (p ≤.1). Both BMI and CES-D scores were considered as continuous variables in the final regression model. Statistical analyses were performed using SAS 9.2 (SAS Institute, Inc., Cary, NC) and STATA 11.0 (StataCorp, College Station, TX).
RESULTS
A total of 1,412 women were included in our analysis. UI was reported by 52.8% (n/N = 745/1,412) of older women. Daily UI was reported by 12.5% of women and 40.2% of women reported some UI (weekly, monthly, or yearly). (Table 1) Mean number of medical comorbidities increased with increased incontinence frequency (p <.0001). Women with increasing incontinence frequency were less likely to report their health status somewhat or much better than their peers (p=.04).
Table 1.
Demographics of community-dwelling older women from NSHAP database by urinary incontinence category. Weighted.
| Variable | Unweighted Respondents N=1,412 | Daily urinary incontinence N=177 | Some urinary incontinence N=568 | No urinary incontinence N=667 | P |
|---|---|---|---|---|---|
| Age Category: | 0.0124 | ||||
| 57-64 | 463 | 36.7 (28.1-45.3) | 43.9 (39.1-48.7) | 37.6 (33.2-42) | |
| 65-74 | 495 | 29 (22.1-35.8) | 33.1 (29.1-37) | 37.8 (33.1-42.5) | |
| 75-85 | 454 | 34.4 (25.2-43.5) | 23 (19.5-26.6) | 24.6 (21.4-27.8) | |
| Race/Ethnicity | 0.0016 | ||||
| White | 991 | 84.5 (76.8-92.3) | 84.3 (81.1-87.5) | 77.3 (72.4-82.2) | |
| Black | 261 | 8.3 (4.3-12.4) | 8.4 (5.9-10.9) | 13.6 (9.6-17.7) | |
| Hispanic, non-black | 126 | 6.2 (0-12.9) | 6.2 (3.5-8.9) | 6 (2.7-9.2) | |
| Other | 26 | 0.9 (0-2.2) | 1.1 (0.4-1.8) | 3.1 (0.9-5.3) | |
| Health Insurance | 0.0209 | ||||
| Medicaid or Medicare | 302 | 30.9 (20.6-41.2) | 18.3 (13.4-23.1) | 22.1 (18.2-26.1) | |
| Private Insurance | 662 | 50.4 (39.1-61.7) | 65.5 (59.8-71.2) | 61 (56.1-65.8) | |
| Other | 187 | 18.7 (12.2-25.3) | 16.3 (12.5-20) | 16.9 (14-19.9) | |
| Education | 0.6986 | ||||
| Less than high school | 319 | 19.9 (12.2-27.5) | 16.7 (13.3-20.1) | 19.7 (15.9-23.6) | |
| High school or equiv. | 418 | 32.2 (24-40.5) | 28.2 (23.8-32.5) | 30.8 (25.8-35.8) | |
| Some college | 432 | 30.2 (21.4-39.1) | 35.5 (29.9-41.1) | 31.3 (27.3-35.3) | |
| Bachelor's degree or higher | 243 | 17.6 (9.5-25.8) | 19.7 (15.3-24.1) | 18.1 (13.8-22.5) | |
| Health Status Relative to Age Peers | 0.0404 | ||||
| Much worse/Somewhat worse/about the same | 460 | 49.7 (40.6-58.7) | 39.2 (33.9-44.5) | 35.5 (29.5-41.4) | |
| Somewhat/Much better | 725 | 50.3 (41.3-59.4) | 60.8 (55.5-66.1) | 64.5 (58.6-70.5) | |
| Parity | 0.5399 | ||||
| No live births | 32 | 2.2 (0.1-4.4) | 1.6 (0.6-2.7) | 2.6 (0.9-4.3) | |
| ≥ 1 live births | 1273 | 97.8 (95.6-99.9) | 98.4 (97.3-99.4) | 97.4 (95.7-99.1) | |
| BMI (kg/m2, Mean 95% CI) | 1310 | 31 (29.7-32.2) | 29.4 (28.8-30.1) | 28.1 (27.5-28.7) | 0.0002 |
| Medical Comorbidities (Median 95% CI) | 1412 | 2.3 (1.9-2.7) | 1.6 (1.5-1.8) | 1.3 (1.1-1.4) | <.0001 |
| CES-D Score (Mean 95% CI) | 1385 | 6.7 (5.7-7.8) | 6 (5.5-6.5) | 5 (4.6-5.4) | 0.0014 |
All values listed as a weighted estimate (95% Confidence Interval) unless otherwise specified.
P-values < .05 were considered statistically significant.
BMI: Body Mass Index
CES-D: Center for Epidemiological Studies-Depression Scale. Range 0–33; higher score indicates greater depressive symptomology
Women with increasing frequency of UI were more likely to report difficulty or dependence with each of the 7 ADLs, including the ADL specifically examining the ability to use the toilet independently (p <.001 for all). (Table 2). Among women with daily UI, 62.1% (95% CI 54.2%, 70.1%) reported composite functional disability. (Table 2) Among women with daily UI, 23.6% (95% CI 16.8%, 30.5%) reported difficulty or dependence with using the toilet.
Table 2.
Activities of daily living in community-dwelling older women by urinary incontinence category. Weighted.
| Variable | Unweighted Respondents N= 1,412 | Daily urinary incontinence N=177 | Some urinary incontinence N=568 | No urinary incontinence N=667 | P |
|---|---|---|---|---|---|
| Walking across the room | <.0001 | ||||
| Independent | 1201 | 76.7 (69.2-84.3) | 86.4 (83.4-89.4) | 90.9 (88.6-93.3) | |
| Independent with difficulty | 199 | 21.5 (14.3-28.7) | 13.3 (10.3-16.3) | 8.5 (6.2-10.8) | |
| Dependent | 12 | 1.8 (0-3.5) | 0.3 (0-0.7) | 0.5 (0-1) | |
| Walking one block | <.0001 | ||||
| Independent | 958 | 54.9 (46.7-63.1) | 70.9 (66.7-75) | 78.6 (75.3-81.8) | |
| Independent with difficulty | 365 | 33.5 (26.7-40.2) | 24.1 (20.7-27.5) | 18.3 (15.3-21.3) | |
| Dependent | 88 | 11.6 (5.8-17.5) | 5 (3.3-6.7) | 3.1 (1.8-4.4) | |
| Dressing | <.0001 | ||||
| Independent | 1193 | 70.3 (62.8-77.8) | 84.8 (82-87.6) | 90.1 (86.9-93.2) | |
| Independent with difficulty | 211 | 28.3 (21-35.6) | 14.8 (12-17.6) | 9.6 (6.6-12.7) | |
| Dependent | 8 | 1.4 (0-3) | 0.4 (0-1) | 0.3 (0-0.8) | |
| Bathing or showering | <.0001 | ||||
| Independent | 1259 | 79.2 (73.4-85) | 90.9 (88.4-93.4) | 94 (92-96) | |
| Independent with difficulty | 141 | 20.5 (14.7-26.3) | 8.3 (5.8-10.9) | 5.4 (3.6-7.2) | |
| Dependent | 11 | 0.4 (0-0.9) | 0.8 (0-1.5) | 0.6 (0-1.2) | |
| Eating | <.0001 | ||||
| Independent | 1339 | 90.7 (85.4-95.9) | 95.1 (93.6-96.7) | 97.1 (95.8-98.4) | |
| Independent with difficulty | 71 | 9.3 (4.1-14.6) | 4.9 (3.3-6.4) | 2.7 (1.5-3.9) | |
| Dependent | 2 | 0 | 0 | 0.2 (0-0.5) | |
| Getting in and out of bed | <.0001 | ||||
| Independent | 1210 | 75.3 (68.3-82.2) | 85.6 (82.6-88.7) | 91.1 (88.8-93.4) | |
| Independent with difficulty | 197 | 24.4 (17.4-31.3) | 14.4 (11.3-17.4) | 8.5 (6.4-10.6) | |
| Dependent | 5 | 0.4 (0-0.9) | 0 | 0.4 (0-1.1) | |
| Using the toilet | <.0001 | ||||
| Independent | 1214 | 76.4 (69.5-83.2) | 84.2 (81.3-87.2) | 92.1 (90.2-94.1) | |
| Independent with difficulty | 196 | 23.5 (16.7-30.2) | 15.8 (12.8-18.7) | 7.8 (5.8-9.7) | |
| Dependent | 2 | 0.2 (0-0.5) | 0 | 0.1 (0-0.3) | |
| Composite functional statusa | <.0001 | ||||
| Independent | 836 | 37.9 (29.9-45.8) | 59.7 (55.4-64.1) | 72.7 (68.6-76.8) | |
| Independent with difficulty | 484 | 50 (41.4-58.6) | 35.1 (31.4-38.8) | 24 (20.1-27.9) | |
| Dependent | 92 | 12.1 (6.8-17.5) | 5.2 (3.6-6.7) | 3.3 (1.9-4.7) | |
All values listed a weighted estimate (95% Confidence Interval) unless otherwise specified.
P-values < .05 were considered statistically significant.
Composite functional status Independent = no difficulty or dependence on any activity of daily living. Independent with difficulty = difficulty on any activity of daily living (but no dependence for any ADLs) Dependent = dependence on any activity of daily living
After adjusting for age category, race/ethnicity, education level, and parity, women with daily UI had 3.31 increased odds of functional difficulty or dependence compared with older women without UI. (Table 3) Other significant risk factors for increased functional difficulty were perceived health status relative to peers, BMI, number of medical comorbidities and depressive symptoms. (Table 3)
Table 3.
Multivariate Logistic Regression Model for composite functional disability among all community-dwelling older women (N= 1412)
| Variable | Adjusted OR | 95% CI | p-value | |
|---|---|---|---|---|
| Urinary incontinence frequency | <.0001 | |||
| No urinary incontinence | 1 | |||
| Some urinary incontinence | 1.61 | 1.14 | 2.23 | |
| Daily urinary incontinence | 3.31 | 1.80 | 6.08 | |
| Age Group, years | 0.006 | |||
| 57-64 | 1 | |||
| 65-74 | 0.87 | 0.61 | 1.25 | |
| 75-85 | 1.71 | 1.11 | 2.64 | |
| Race/Ethnicity | 0.345 | |||
| White | 1 | |||
| Black | 1.57 | 0.93 | 2.66 | |
| Hispanic, non-black | 0.91 | 0.50 | 1.64 | |
| Other | 0.88 | 0.31 | 2.52 | |
| Education | 0.010 | |||
| Less than High School | 1 | |||
| High School or Equivalent | 0.51 | 0.31 | 0.86 | |
| Some College | 0.55 | 0.34 | 0.89 | |
| Bachelor's Degree or Higher | 0.37 | 0.20 | 0.66 | |
| Health Status Relative to Age Peers | ||||
| Somewhat better/Much better | 1 | |||
| Much worse/Somewhat worse/About the same | 2.09 | 1.47 | 2.99 | <.0001 |
| Parity (No live births= referent) | 1 | |||
| ≥1 live birth | 0.62 | 0.30 | 1.28 | 0.199 |
| BMI (kg/m2) | 1.09 | 1.05 | 1.12 | <.0001 |
| Number of Medical Comorbidities | 1.50 | 1.30 | 1.71 | <.0001 |
| CES-D Score | 1.10 | 1.06 | 1.14 | <.0001 |
CI = confidence interval
BMI = body mass index
CES-D = Center for Epidemiological Studies-Depression Scale
Women with daily UI were not significantly more likely to have compromised mobility, defined as performance on the timed “Get up and Go” test, compared to women with less frequent UI. (Table 4) Women with daily UI were more likely to report not being physically active in the last month compared with women with less frequent UI and no UI [26.2% (95% CI 16.9, 35.5 vs.20.1% (95% CI 16.2, 24) vs. 14.3% (95% CI 11.5, 17.2); p=.004]. Women with daily UI were more likely to report falling at least once in the last 12 months compared with other women [33.2% (95% CI 23.6, 42.9) vs. 25.9% (95% CI 21.3, 30.5) vs. 22.6 (18.7, 26.4), p =.04].
Table 4.
Mobility in community-dwelling older women by urinary incontinence category. Weighted
| Daily urinary incontinence N= 177 | Some urinary incontinence N = 568 | No urinary incontinence N= 667 | P | |
|---|---|---|---|---|
| *Compromised mobility | 52.5 (37.1-68) | 51.7 (43.7-59.6) | 51.3 (43.7-58.9) | 0.99 |
| Walked unsteadily | 11 (3.3-18.7) | 10.4 (6.5-14.4) | 7.5 (3.6-11.5) | 0.46 |
| Used cane or walker | 6.1 (0.3-11.8) | 2.9 (0.4-5.4) | 1.5 (0.2-2.8) | 0.12 |
| Frequency of physical activity | ||||
| Never or < 1 time per month | 26.2 (16.9-35.5) | 20.1 (16.2-24) | 14.3 (11.5-17.2) | 0.004 |
| Fallen in the past 12 months | 33.2 (23.6-42.9) | 25.9 (21.3-30.5) | 22.6 (18.7-26.4) | 0.046 |
| Number of falls in past 12 months (Mean, 95% Confidence Interval) | 3.9 (1.7-6.1) | 2.2 (1.8-2.5) | 1.9 (1.6-2.2) | 0.111 |
All values listed as a weighted estimate (95% Confidence Interval) unless otherwise specified.
Compromised mobility was determined based on performance of the “Get Up and Go” test. Women were categorized as having compromised mobility if total time ≥ 12 seconds to complete.
DISCUSSION
In a nationally representative cohort of community-dwelling women age 57 to 85, 12.5% of women report daily UI. We found the prevalence of functional disability increased in all ADLs with increasing frequency of UI. Women with both daily UI and functional disability tended to be older, have a higher BMI, and have more medical comorbidities. After adjusting for age category, race, education level, health status, parity, BMI, medical comorbidities, and depressive symptoms, women with daily UI had a significantly increased odds functional disability and dependence compared with older women without UI. Over 60% of women with daily UI reported functional difficulty or dependence with any ADL and 1/4 of women with daily UI specifically reported difficulty or dependence with using the toilet. Although not specifically examined in this study, we hypothesize that due to the high prevalence of both UI and functional disability in community-dwelling older women in the United States, evaluation and treatment of women presenting for symptoms of UI may be improved by considering functional status.
Compromised mobility has also been shown to have the strong and consistent associations with adverse outcomes of aging.(19) We expected compromised mobility to play a role in women with UI due to limitations preventing them from reaching the toilet on time. However, we did not show a significant difference in mobility measured by the “Get Up and Go” test in women with and without UI. We hypothesize that we did not find significant differences in mobility because we did not have information on the specific types of UI, namely urgency UI and stress UI. Fritel et al. explored the association of mobility and UI in 1,942 community-dwelling older women in France.(20) An association between slow walking speed and urgency UI (Adjusted OR 2.17 (95% CI 1.36, 3.45) was demonstrated. Interestingly, Fritel et al did not demonstrate a significant association between stress UI and mobility.(20) Unfortunately, one limitation of the NSHAP is that does not contain information on certain variables. Specifically, we do not have information on either type of urinary incontinence (stress UI, urgency UI, or mixed UI) or severity of UI, although information on UI frequency was available. We did find that women with daily UI had other indicators of compromised mobility as measured by reported physical activity and falls in the last 12 months. Also, when we examined reports of difficulty with ADLs, 453 women reported difficulty or dependence for walking more than one block with increasing disability with increasing urinary incontinence frequency (p<.001). Although walking one block is considered an ADL, this self-reported question also reflects mobility to some extent as well. There is a growing body of evidence demonstrating that compromised mobility, gait disturbances and falls result from decreased muscle strength, balance disorders and cognitive impairments.(21, 22) Another reason we may not have found an association between mobility and UI could be related to the lack of complex measurements of balance and cognitive function in the NSHAP.
Our study is limited by its cross-sectional design, preventing causality from being determined. Women may reduce physical activity due to fear of accidental urine leakage while other women may have reduce physical activity and increased functional limitations that cause them more difficulty getting to the toilet on time. Women have reported limiting physical activity to avoid the embarrassment of urine leakage.(23) Likely, as suggested by Sung et al., the relationship between UI and mobility is “complex and...birectional”.(24) However, from this nationally-representative sample we have been able to estimate the prevalence of both daily UI and functional disability in community-dwelling older women and demonstrate a significant association. Additional limitations of this study include that it was a secondary analysis of an existing dataset and the NHSAP was not specifically designed to evaluate this question. Finally, we were limited by the questions asked on UI to NSHAP participants. Although not validated, the UI question used in this analysis was asked consistently on all women and information on both the presence of UI and frequency was obtained.
Both functional status and mobility are dynamic conditions. Targeted interventions, especially interventions aimed at increasing physical activity, can improve mobility and thereby decrease adverse outcomes of aging.(25) A pilot program of weekly supervised group sessions of pelvic floor muscle exercises (PFME) and physical therapy for 6 months in female nursing home residents has been shown to improve physical performance women who participated in PFME sessions compared to women given incontinence pads prescription and increased toileting assistance.(26) Mean UI episodes were reduced for both the PFME participants (baseline 9.0 (±12.2) to follow-up 4.4 (±7.4)) and women given incontinence pads prescription and increased toileting assistance (baseline 9.3 (±11.3) to follow-up 5.4 (±8.5)). The finding of improved physical performance with supervised PFME are especially positive given that the nursing home population often experiences more severe urine leakage than community-dwelling older women.(26)
In summary, we found a high concurrent prevalence of functional disability among women with UI. Women with UI were more likely to report falls in the last 12 months and less likely to report physical activity. In women with functional limitations preventing them from reaching the toilet, treatments targeting mobility may prove to be more beneficial than focusing treatments specifically on the pelvic floor or detrusor muscle.
Acknowledgments
This research was supported by a grant from the American Urogynecologic Society (AUGS) Foundation. Dr. Erekson was supported in part through a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (NIH/NIA #P30AG021342). The National Social Life, Health and Aging Project was conducted by a grant from the National Institute on Aging (NIH/NIA #R01 AG021487).
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