Total and free 25-hydroxyvitamin D concentrations and risk of urinary incontinence in women participating in Nurses Health Studies I & II.

BACKGROUND: Urgency urinary incontinence (UUI) occurs in >40% of older women. Our objective was to examine the relationship of total and free plasma 25-hydroxyvitamin D (25(OH)D) and UUI to evaluate vitamin D status as a novel target for prevention of UUI. METHODS: We conducted a nested case control study using the Nurses' Health Study (NHS) and NHS II. Using stored plasma samples from 2000, we measured total 25(OH)D, free 25(OH)D, and intact parathyroid hormone (PTH) levels and examined their relationship to incident UUI from 2000 to 2013. Plasma biomarker levels were categorized as quartiles. Multivariable-adjusted odds ratios of UUI were estimated by conditional logistic regression models (with matching by age) across categories of each biomarker and covariates. RESULTS: The analytic sample included 398 cases of incident UUI and 398 matched controls with a mean age of 50 years. We found a strong correlation of plasma levels of total 25(OH)D with free 25(OH)D (r=0.5). Plasma total 25(OH)D and free 25(OH)D concentrations were negatively correlated with PTH (r=-0.08 AND -0.09, respectively). Overall, we found no evidence that levels of total plasma 25(OH)D, free 25(OH)D, or PTH were related to incident UUI after adjustment for obesity, physical activity, cigarette smoking, menopausal status, hypertension, and type 2 diabetes. CONCLUSIONS: Free plasma 25(OH)D by quartile, as well as total plasma 25(OH)D, was not associated with incident UUI in women. We found that plasma total and free 25(OH)D were highly correlated with each other and inversely correlated with PTH. Plasma free 25(OH)D did not provide additional predictive value in determining risk of UUI.

Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island.

BACKGROUND: We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner. METHODS: This study utilized a quasi-experimental interrupted time series design to implement EQUiPPED, a three-prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre-and post-intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression. RESULTS: 247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre-implementation period (July 2018-July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post-implementation period (October 2019-January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre-implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post-implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines. CONCLUSIONS: EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID-19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.

Perioperative Mobile Telehealth Program for Post-Prostatectomy Incontinence: A Randomized Clinical Trial.

PURPOSE: Perioperative pelvic floor muscle training can hasten recovery of bladder control and reduce severity of urinary incontinence following radical prostatectomy. Nevertheless, most men undergoing prostatectomy do not receive this training. The purpose of this trial was to test the effectiveness of interactive mobile telehealth (mHealth) to deliver an evidence-based perioperative behavioral training program for post-prostatectomy incontinence. MATERIALS AND METHODS: This was a 3-site, 2-arm, randomized trial (2014-2019). Men with prostate cancer scheduled to undergo radical prostatectomy were randomized to a perioperative behavioral program (education, pelvic floor muscle training, progressive exercises, bladder control techniques) or a general prostate cancer education control condition, both delivered by mHealth for 1-4 weeks preoperatively and 8 weeks postoperatively. The primary outcome was time to continence following surgery measured by the ICIQ (International Consultation on Incontinence Questionnaire) Short-Form. Secondary outcomes measured at 6, 9 and 12 months included Urinary Incontinence Subscale of Expanded Prostate Cancer Index Composite; pad use; International Prostate Symptom Score QoL Question and Global Perception of Improvement. RESULTS: A total of 245 men (ages 42-78 years; mean=61.7) were randomized. Survival analysis using the Kaplan-Meier estimate showed no statistically significant between-group differences in time to continence. Analyses at 6 months indicated no statistically significant between-group differences in ICIQ scores (mean=7.1 vs 7.0, p=0.7) or other secondary outcomes. CONCLUSIONS: mHealth delivery of a perioperative program to reduce post-prostatectomy incontinence was not more effective than an mHealth education program. More research is needed to assess whether perioperative mHealth programs can be a helpful addition to standard prostate cancer care.

An Exploratory Analysis of Tamsulosin for Overactive Bladder (OAB) in Men With Varying Voiding Symptom Burden.

OBJECTIVE: To evaluate tamsulosin (α-blocker therapy) for male overactive bladder (OAB) and to examine if indicators of concomitant benign prostatic hyperplasia are associated with OAB symptom improvement. MATERIALS AND METHODS: This was a planned, exploratory analysis of a 4-week, α-blocker (tamsulosin 0.4 mg) run-in phase of the Male Overactive Bladder Trial in Veterans (MOTIVE). Participants with urinary urgency and urinary frequency (> 8 voids/24 hours) completed bladder diaries, answered symptom questionnaires (AUA-7 SI), and had post-void residual and noninvasive uroflowmetry measurement. RESULTS: A total of 116 male Veterans aged 42-88 years with OAB participated. There were statistically significant reductions in voiding frequency (11.3 > 10.0 voids/24 hours, P < .0001), urgency scores (mean 2.5-2.2 points, P < .0001), and nightly nocturia (2.1 > 1.8, P < .001). Only baseline AUA-7 SI total and voiding subscale categories (mild, moderate, severe) were associated with significant reduction in AUA-7 SI total score. For continuous variables, only AUA-7 SI baseline total score was associated with AUA-7 SI storage symptom changes. No other baseline measures were associated with changes in urgency, frequency, or nocturia. CONCLUSION: Initiation of short course tamsulosin therapy in men was associated with statistical reduction in OAB symptoms. Baseline post-void residual, uroflow rate, and the voiding symptom subscore of the AUA-7 SI were not predictive of OAB symptom improvement with tamsulosin. These findings merits further exploration.

Comorbidities, Age, and Polypharmacy Limit the Use by US Older Adults with Nocturia of the Only FDA-approved Drugs for the Symptom.

PURPOSE: The goal of this study was to determine if the US adult population with nocturia (waking from sleep at night to void) can easily take medications (desmopressin acetate) approved by the US Food and Drug Administration for nocturia. The study examined: (1) the prevalence of comorbid conditions, laboratory abnormalities, and concomitant medications that increase risk of desmopressin use; and (2) whether these factors are associated with age or nocturia frequency. METHODS: Using a cross-sectional analysis of four US National Health and Nutrition Examination Survey (NHANES) waves (2005-2012), a total of 4111 participants aged ≥50 years who reported ≥2 nightly episodes of nocturia were identified. The main outcome was frequency of contraindications and drug interactions as described in US Food and Drug Administration-approved prescribing information. These prescribing concerns were matched to examination findings, medical conditions, concomitant medications, and laboratory results of NHANES participants. The associations between prescribing concerns and nocturia severity and age groups were examined. FINDINGS: The mean participant age was 65.7 years (95% CI, 65.3-66.1), and 45.5% were male. Desmopressin prescribing concerns were present in 80.5% (95% CI, 78.0-82.9) of those ≥50 years of age with nocturia; 50.0% (95% CI, 47.0-53.0) had contraindications, and 41.6% (95% CI, 39.3-44.0) took a concomitant drug that could increase risk of low serum sodium. Desmopressin contraindications were higher with older age (P < 0.001) and present in 73.2% (95% CI, 69.3-77.1) of those ≥80 years of age. IMPLICATIONS: Using NHANES data, this study showed that older US adults with nocturia have a high prevalence of medical conditions, concomitant medications, and baseline laboratory abnormalities that likely increase the risk of potentially severe adverse side effects from desmopressin use. A medication designed and approved for a clinical symptom that is most common in older adults could not be taken by most of the older adults with the symptom.

Long-term metformin treatment and risk of peripheral neuropathy in older Veterans.

AIM: Our objective was to assess whether increased duration of metformin therapy is associated with incident peripheral neuropathy (PN) in older Veterans with diabetes. METHODS: Using national Veterans Affairs registry data from 2002 to 2015, we examined Veterans (50 + years) with diabetes. Long-term metformin therapy was defined as prescription ≥ 500 mg/day, filled for ≥ 6 consecutive months. Metformin therapy duration was examined both as continuous and categorical measures. Incident PN was defined by medical chart review. We estimated unadjusted and adjusted (variables selecteda priori)odds ratios (OR) and 95% confidence intervals (CI) using logistic regression. RESULTS: The study included n = 210,004 individuals (mean ± SD: age: 66.2 ± 8.4 yrs, 96% male) prescribed metformin for 47.0 ± 34.0 months. Nineteen percent developed PN during follow-up. After adjusting for age, body mass index, duration of time receiving health care within the VA, smoking status, alcohol abuse, and vitamin B12 testing and treatment, the number of months of metformin treatment was associated with elevated odds for incident PN (aOR (metformin treatment - continuous) = 1.009 (95% CI = 1.009, 1.010); aOR (metformin treatment - categorical (ref: 6-<18 months): 18-<44.1 months = 1.57 (1.51-1.63), 44.1-<61 months = 2.05 (1.97-2.14), 61 + months = 2.69 (2.58-2.79), all p-values < 0.0001). CONCLUSION: Our study suggests that Veterans treated for at least 18 months with metformin are approximately 2-3 times more likely to develop PN than those treated at least six, but<18 months. Future studies are needed to determine whether the association we found may be due to a decline in vitamin B12 status following metformin initiation.

Urological function and dysfunction in aging: Diagnosis and treatment.

Urinary symptoms worsen further the quality of life of persons already burdened by neurologic disease. Urinary symptoms frequently occur in the setting of neurologic diseases such as Parkinson disease and Parkinson-plus syndromes, multiple sclerosis, and stroke. Urinary incontinence is associated with increased caregiver burden and enhances the risk of institutionalization among those living with dementia. Nocturia is associated with impaired sleep and work productivity. Providing patient-centered care for urinary symptoms involves assessing patient and family goals for care and incorporating a multicomponent assessment and treatment plan to align treatment options with the goals for care. Lifestyle and behavioral therapies are available as first-line treatment for most urinary symptoms. Consideration of drug therapy should aim to minimize the potential for adverse drug events such as orthostatic hypotension when using α blockers for men with concomitant prostate enlargement or anticholinergic side effects with anticholinergic bladder relaxant therapy. Interventional therapies such as percutaneous nerve stimulation, cystoscopic botulinum toxin injection, and sacral neuromodulation are available for patients who do not have significant urinary retention at baseline. Containment strategies aim to prevent skin irritation and provide support. With a patient-centered approach, providers empower patients to control and contain urinary symptoms and, thus, maintain confidence and social engagement.

Vitamin D and lower urinary tract symptoms among US men: results from the 2005-2006 National Health and Nutrition Examination Survey.

OBJECTIVE: To evaluate the association of vitamin D levels and lower urinary tract symptoms (LUTS) among US men. MATERIAL AND METHODS: Data were analyzed for 2387 men (≥20 years) who participated in the 2005-2006 cycle of the National Health and Nutrition Examination Survey, a cross-sectional survey of the US noninstitutionalized population. LUTS included nocturia, incomplete emptying, hesitancy, and urinary incontinence (UI). Plasma 25-hydroxyvitamin D was categorized as ≥30 ng/mL (normal), 20-30 ng/mL (insufficiency), and <20 ng/mL (deficiency). Other factors included age, race/ethnicity, education, body mass index, self-reported health status, chronic diseases, and prior diagnosis of benign prostatic enlargement and/or prostate cancer (men ≥40 years of age). Prevalence and prevalence odds ratios (POR) were estimated from a multivariable logistic regression analysis using appropriate sampling weights. RESULTS: A majority (89%, n = 1241) had vitamin D levels <30 ng/mL, of whom 55% (n = 684) had vitamin D levels <20 ng/mL. Vitamin D levels ranged from 2-56 ng/mL (median 19 ng/mL, mean ± SD 19.9 ± 8.0). Among the 1388 (58%) men with LUTS data and vitamin D levels, 48% (n = 666) had at least 1 LUTS. In multivariable analyses adjusting for age and race norms, vitamin D deficiency was associated with the presence of moderate-severe UI (POR 1.8, 95% CI 1.1, 3.0) and at least 1 LUTS (POR 1.4, 95% CI 1.0, 2.0). CONCLUSION: Vitamin D insufficiency and deficiency are highly prevalent among adult men in the US, and vitamin D deficiency is associated with moderate-severe UI and the presence of at least 1 LUTS.

Prevalence of nocturia in United States men: results from the National Health and Nutrition Examination Survey.

PURPOSE: We estimated the prevalence of nocturia in the United States male population and identified associated factors. MATERIALS AND METHODS: Data were analyzed for 5,297 men (20 years old or older) who participated in the 2005-2006 and 2007-2008 cycles of the NHANES, a cross-sectional survey of the United States noninstitutionalized population. Getting up 2 or more times at night to urinate was coded as nocturia. Potential factors included age, race/ethnicity, education, waist circumference, self-reported health status, chronic diseases, and prior diagnosis of benign prostatic enlargement and/or prostate cancer (men 40 years old or older). Prevalence and prevalence odds ratios were estimated from a multivariable logistic regression analysis using appropriate sampling weights. RESULTS: The prevalence of nocturia was 21% (weighted 95% CI 19.3-23.0). Nocturia increased in prevalence with age (p<0.001) from 8.2% (CI 6.7-10.2) in men 20 to 34 years old up to 55.8% (CI 51.3-60.2) in men 75 years old or older. More nonHispanic black men had nocturia (30.2%, CI 26.7-34.1) than other racial/ethnic groups (20.1%, CI 18.1-22.1, p<0.001). Significant factors included 10-year increase in age (POR 1.5, CI 1.5-1.6), nonHispanic black race/ethnicity (POR 2.0, CI 1.6-2.7), fair/poor self-rated health (POR 1.5, CI 1.2-1.9), major depression (POR 2.5, CI 1.6-3.9), hypertension (POR 1.4, CI 1.0-1.9) and arthritis (POR 1.3, CI 1.0-1.7). Among men 40 years old or older benign prostatic enlargement (POR 1.4, CI 1.1-1.8) and prostate cancer (POR 1.6, CI 1.0-2.4) were associated with nocturia. CONCLUSIONS: After adjusting for age and race norms nocturia was common among United States men. NonHispanic black men had greater odds of nocturia even when controlling for other factors.

A multicomponent behavioural and drug intervention for nocturia in elderly men: rationale and pilot results.

OBJECTIVES To evaluate the number of medical and urological conditions associated with nocturia in a cohort of older men who were primary-care enrolees, and to assess the feasibility and efficacy of using a multicomponent intervention to reduce nocturia and its bother. SUBJECTS AND METHODS Men aged > or =50 years and with two or more episodes of nocturia were recruited from the primary-care clinics at one Veterans Affairs Medical Center to participate in a 4-week, open-label, prospective pilot study. A multicomponent intervention composed of behavioural therapy and targeted drug therapy was administered according to a specified protocol based upon identified risk factors for nocturia. Outcome measures included self-reported nocturia and bother on the American Urological Association (AUA)-7 Symptom Index, 3-day bladder diaries and self-reported sleep-related measures recorded using 7-day sleep diaries. RESULTS Fifty-five men completed the protocol (mean age 67 years, sd 8.3); they had a mean of 4.5 of nine defined conditions potentially related to nocturia. Highly prevalent conditions included moderate-to-severe benign prostatic hyperplasia (87%), hypertension (86%) and urinary frequency (71%). The mean diary-recorded nocturia decreased from 2.6 to 1.9 (P < 0.001), and bother score reduced from 3.1 to 1.1, representing a change from a 'medium' to a 'very small' problem (on a 5-point scale). Sleep diary-derived measures also improved significantly (time to initiate sleep, time to return to sleep after awakening, quality of sleep). CONCLUSIONS Given that individual older patients often have multiple coexistent risk factors for nocturia, identifying a principal cause of nocturia, a concept emphasized in treatment guidelines, proved to be difficult. Implementing a multicomponent behavioural intervention combined with drug(s) was feasible in older men and reduced nocturia frequency, bother from nocturia, and time to initiate sleep, within 4 weeks. These promising results merit repeating using a randomized, controlled trial.