Nocturia severely impairs the sleep quality of nursing home residents: results from a multi-center study.

OBJECTIVES: To assess the association between self-reported sleep quality and nocturia in nursing home residents. METHODS: The association between self-reported poor sleep quality and nocturia was examined in eighty nursing home residents from two nursing facilities using logistic regression analysis. RESULTS: Poor sleep quality was reported by 29% of the eighty participants (median age 89±7 years, 77% of women). Nocturia was more frequent in patients with versus without self-reported poor sleep quality (78% vs 47%, p=0.01). Nocturia was independently associated with self-reported poor sleep quality after controlling for age, gender, self-rated health status, cognitive frailty score, antidepressant and hypnosedative use (OR[95%CI] of 6.1[1.8-25.4]). CONCLUSION: Nocturia severely impaired sleep quality in nursing home residents. Nocturia should be investigated in nursing home residents to optimize sleep quality.

The Bladder at Night during Hospitalisation: Towards optimal care for elderly patients with nocturia.

OBJECTIVE: This study aimed to describe the characteristics of nocturia in older hospitalised patients and to explore knowledge, beliefs and experiences associated with night toileting while in hospital in order to identify unmet care needs. METHODS: A multisite mixed methods cross-sectional study of older hospitalised adults who were admitted for ≥2 days was conducted using a standardised researcher-administered questionnaire. An additional cohort 16 older hospitalised adults with nocturia >twice per night were interviewed to understand the experience and impact of nocturia during hospitalisation. RESULTS: Nocturia was experienced by 260 out of 308 participants. In-hospital nocturia was significantly correlated with nocturia in the month preceding admission, high diurnal voiding frequency and nocturnal urinary urgency. Bother was attributed to multiple nocturia episodes. Participants had poor knowledge and understanding of nocturia and believed the symptom to be a normal occurrence; only 20% had discussed management with staff. Disrupted sleep and fear of falling were common in older immobile participants with nocturia. CONCLUSION: Nocturia is highly prevalent in hospitalised older people. Toileting multiple times at night bothers patients, disrupts sleep, heightens a fear of falling yet is rarely addressed in ward management plans. A screening process to identify, assess, provide education and intervene for nocturia has the potential to improve wellbeing, safety at night and to address risk factors.

Phenotyping nocturnal polyuria: circadian and age-related variations in diuresis rate, free water clearance and sodium clearance.

BACKGROUND: this study compares diuresis rate, sodium clearance and free water clearance (FWC) by age and time of day (nighttime vs. daytime) in subjects with and without nocturnal polyuria (NP) to determine whether these variables affect the phenotype of NP. METHODS: post hoc analysis of two prospective observational studies. Eight urine samples collected at 3-h intervals and a single blood sample were used to calculate daytime (10a/1p/4p/7p/10p) and nighttime (1a/4a/7a) diuresis rates, sodium clearance and FWC. Three mixed linear models were constructed for diuresis rate, sodium clearance and FWC using four predictor variables: NP status (present [nocturnal urine production >90 ml/h] vs. absent [≤90 ml/h]), time of day, age and study identification. RESULTS: subjects with NP experienced higher nighttime versus daytime diuresis rates, sodium clearance and FWC. Regardless of NP status, increased age was accompanied by an increase in the ratio of nighttime/daytime diuresis rate, nighttime sodium clearance and daytime sodium clearance. FWC showed a complex age effect, which was independent of time of day or NP status. CONCLUSIONS: age-related increases in nighttime/daytime diuresis rate, 24-h sodium clearance and 24-h FWC are not specific to subjects with NP. The age-related surge in either nocturnal sodium clearance or nocturnal FWC may represent the relevant substrate for behavioural or pharmacologic interventions targeting sodium diuresis or free water diuresis, respectively. Increases in FWC in older age groups may reflect impaired circadian rhythmicity of endogenous AVP or changes in responsiveness of the aged nephron to water clearance.

Development of a multivariate prediction model for nocturia, based on urinary tract etiologies.

PURPOSE: The main objective of our study was to determine which combination of modifiable and non-modifiable parameters that could discriminate patients with nocturia from those without nocturia. This was a post-hoc analysis of 3 prospective, observational studies conducted in Ghent University. Participants completed frequency volume chart (FVC) to compare characteristics between patients with and without nocturia. METHOD: This was a post hoc analysis of three prospective, observational studies conducted in Ghent University. Participants completed frequency volume chart (FVC) to compare characteristics between adults with and without nocturia. Study 1: adults with and without nocturia (n = 148); Study 2: patients ≥65 years with and without nocturnal LUTS (n = 54); Study 3: menopausal women before and after hormone replacement therapy (n = 43). All eligible patients (n = 183) completed a FVC during 24 hours (n = 13), 48 hours (n = 30) or 72 hours (n = 140). The combination of algorithms and number of determinants obtaining the best average area under the receiver operating curve (AUC-ROC) led to the final model. Differences between groups were assessed using the AUC-ROC and Mann- Whitney-Wilcoxon tests. Holm corrections were applied for multiple statistical testing. Also, the stability of the feature selection was evaluated. RESULTS: The best discrimination was obtained when 13 determinants were included. However, a logistic regression model based on seven determinants selected with random forest had comparable discrimination including an optimal signature stability. It was able to discriminate almost perfectly between nights with and without nocturia. CONCLUSION: Relevant information to accomplish the excellent predictability of the model is; functional bladder capacity, 24 hours urine output, nocturnal output, age, BMI. The multivariate model used in this analysis provides new insights into combination therapy as it allows simulating the effect of different available treatment modalities and its combinations.

A different way to study frequency volume charts in patients with nocturia.

BACKGROUND: Nocturia results from a mismatch between bladder capacity and nocturnal urine production (NUP), which is determined with a frequency volume charts (FVC). AIM: This is the first study that aimed to describe variations in nocturia severity and its associated factors by evaluating FVCs per single 24 h-period. METHODS: This was a post-hoc analysis of patients who completed a 72 h-FVC in prospective, observational studies. The nocturnal polyuria index (NPi ) was defined as the ratio of nocturnal and 24 h urine output. Subgroups were defined according to variations in nocturia frequency during the three 24 h-periods of the FVC (fluctuating/consistent) and to the number of nocturia episodes during a single night (0/1/≥2). RESULTS: We analyzed 504 24 h-FVC, collected by 168 subjects (58% female) with a median age of 60 (50-68) years. Nocturia frequency fluctuated in 69 (41%) subjects. For the same number of nocturnal voids, we found no differences in NPi and maximum voided volume (MVV) between consistent and fluctuating nocturia frequency. Increasing numbers of nocturnal voids were associated with an increasing NPi in subjects with fluctuating nocturia, while for consistent nocturia, it was linked to an increase in NPi and a decrease in MVV. For both subjects with fluctuating and consistent nocturia, increasing nocturia severity was associated with increasing daytime fluid intake. CONCLUSION: For the same number of nocturnal voids, bladder capacity, and NUP were similar between patients with consistent and fluctuating nocturia. An increasing number of nocturnal voids in subjects with fluctuating nocturia was linked to more NUP and more daytime fluid intake.

Pathophysiology of nocturnal lower urinary tract symptoms in older patients with urinary incontinence.

OBJECTIVES: To explore the mismatch between functional bladder capacity and nocturnal urine production, and to study the pathophysiology of an increased nocturnal urine production in older patients with urinary incontinence. METHODS: The present prospective observational study included adults aged ≥65 years with urinary incontinence. Participants completed questionnaires, frequency volume charts and renal function profiles. The nocturnal lower urinary tract symptom index was defined as nocturnal urine output/maximum voided volume; the nocturnal polyuria index as nocturnal/24 h urine output. RESULTS: The median age (n = 95) was 74 years (69-79), 87% were women and 73% had nocturnal lower urinary tract symptoms (nocturnal urinary incontinence or nocturia ≥2). Participants with nocturnal lower urinary tract symptoms had a significantly higher nocturnal urine output (809 mL vs 650 mL; P = 0.001) and no significant difference in maximum voided volume (350 mL vs 437 mL; P = 0.079) compared with participants without nocturnal lower urinary tract symptoms. Participants (nocturnal polyuria index >33% [n = 56], nocturnal polyuria index >40% [n = 42], nocturnal lower urinary tract symptom index >1.87 [n = 51]) showed higher night-time diuresis rates, free water and sodium clearance compared with during the daytime. Controls (nocturnal polyuria index ≤33% [n = 26], nocturnal polyuria index ≤40% [n = 40], nocturnal lower urinary tract symptom index ≤1.87 [n = 44]) had no circadian rhythm in their diuresis rate or sodium clearance, but more nocturnal free water clearance compared with during the daytime. CONCLUSIONS: The majority of older adults with urinary incontinence present nocturnal lower urinary tract symptoms. An increased nocturnal sodium diuresis seems to be the only mechanism differentiating patients with nocturnal lower urinary tract symptoms from controls.

Prevalence and characteristics of incident falls related to nocturnal toileting in hospitalized patients.

Objectives: Although nocturia is a risk factor for incident falls in the community, studies are required to gain an understanding of incident falls related to nocturnal toileting in hospitals. The aim of this study is to describe the prevalence and characteristics of incident falls in adult hospitalized patients related to nocturnal toileting.Methods: A retrospective review of the electronic incident reporting and learning system and medical records of inpatients that had an incident fall.Results: The prevalence of toileting-related incident falls was 53% (73/137) and 28% of all incident falls were related to nocturnal toileting.Intravenous fluid infusion was associated with falls related to toileting, whereby median perfusion volume during night-time was 375 ml [IQR: 225-578 ml].Conclusions: The prevalence of nocturnal toileting-related incident falls in hospitals is high. Nocturia could be a leading cause of these incident falls. Intravenous fluid infusion might be part of the aetiology of (iatrogenic) nocturia.

Toileting-related falls at night in hospitalised patients: The role of nocturia.

OBJECTIVE: The purpose of this study was to describe the prevalence and characteristics of toileting-related falls in hospitalised older people. METHODS: Retrospective analysis of falls related to night-time toileting in patients 60 years or over in a tertiary hospital during a one-year period. RESULTS: Overall 34% of falls were related to toileting with at least 44% of these falls occurring during the night. Toilet-related falls peaked between 11 pm and 1 am, a period that coincides with maximum supine-induced diuresis. Almost half of night falls occurred at the bedside. In 80% of night toileting-related falls, patients were mobilising without the recommended level of assistance. Half of all patients had no strategies for toileting documented in their care plan. CONCLUSION: Findings support screening for nocturia in older inpatients and implementation of strategies to reduce both the need for toileting at night and risk factors for falling.

Dutch version of the TANGO nocturia screening tool: cross-culturally translation and reliability study in community-dwelling people and nursing home residents.

Objectives: The purpose of this study was to translate and culturally adapt the self-administered screening instrument 'Targeting the individual's Aetiology of Nocturia to Guide Outcomes' (TANGO) into Dutch for Belgium and to assess its test-retest reliability. Methods: This study has a cross-sectional, descriptive study design. Cross-cultural adaption of TANGO into Dutch for Belgium was performed according to a standardized method. Convenience samples of community-dwelling people and NH residents with nocturia (≥1void/night) completed TANGO-D at baseline and 1-2 weeks later. Community-dwelling people filled in the questionnaire at home and the NH residents were interviewed by a study nurse. Results: TANGO-D was completed by 33 community-dwelling middle-aged people and 45 NH residents. Completeness of responses was adequate in both populations and almost all items had positive and negative answers. In the NH residents, 12 out of 22 items required clarification, wherein five items adjustments are essential. Test-retest reliability analysis revealed an overall median Kappa of .75 [IQR: .78-1] in community-dwelling people and .54 [IQR: .31-.65] in NH residents, confirming substantial and moderate agreement, respectively. Conclusion: TANGO-D is a cross-cultural adapted Dutch translation of the original TANGO and showed good test-retest reliability in community-dwelling middle-aged people. However, validation of TANGO is required before use in clinical practice and the addition of a module of environment-related items to extend the utility of the instrumentwhen used in NH is desirable.

Circadian Patterns in Postvoid Residual and Voided Percentage Among Older Women with Urinary Incontinence.

BACKGROUND: Women with urinary incontinence incur an increased risk of elevated postvoid residual (PVR) volume and impaired voiding efficiency (i.e., voided percentage (Void%)), but the clinical significance of these parameters remains poorly described. Further characterization of PVR and voiding efficiency may thus be useful in refining the evaluation and management of urinary incontinence. This study aims to explore possible circadian variations in PVR and Void% in older women with stress (SUI), urge (UUI) and mixed urinary incontinence (MUI). METHODS: A single center prospective study which enrolled a convenience sample of 90 older women who consulted a tertiary referral hospital for urinary incontinence. Participants underwent an extensive medical interview and were hospitalized to complete a 24-h frequency-volume chart (FVC) with PVR measurement after each void (FVCPVR). RESULTS: FVCPVR analysis demonstrated no differences in mean PVR and Void% between patients with SUI, UUI and MUI. Likewise, no daytime or nighttime differences were observed in mean PVR or Void% within or between groups. CONCLUSIONS: No evidence of circadian variation in PVR or Void% was observed in older women with SUI, UUI or MUI.

Smart diapers for nursing home residents with dementia: a pilot study.

Objectives: The objective of the study is to evaluate the use of an experimental smart diaper as an indicator of saturation for diaper change in persons with dementia living in nursing homes. Methods: A multicenter prospective study was conducted in 3 nursing homes amongst 18 residents with dementia. For each resident, a frequency-volume urine chart (FVUC) was kept for 24 h including voided volume and diaper weights, wearing smart diapers. A comparative study was set up between results obtained by smart diapers and data registered in FVUCs. Results: Analysis based on quantification of the agreement between saturation calculated by smart diaper and determined by FVUC indicates that measurements reported by sensor do not correspond with measurements based on FVUC. For the regular diaper, the saturation measured by sensor may be 26% below or 39% above saturation based on FVUC and for the super diaper, respectively, 34% below or 30% above. Discussion: This study indicates that the sensor detects and notifies wetness but is not sensitive enough for using it as an indicator for diaper change in people with severe dementia.

The impact of nocturnal polyuria in older people with nocturnal LUTS.

BACKGROUND: Bladder dysfunctions often express the presence of lower urinary tract symptoms (LUTS) and are common in older people. The aim of this study was to analyze the micturition, incontinence and residual in older subjects, evaluating the role of nocturnal polyuria. METHODS: Eighty-six patients aged 65 or older with invalidating LUTS were hospitalized for 24 hours. The maximum bladder capacity, mean micturition volume, post voiding residual and incontinence volume were recorded and analyzed day-time and night-time. Three groups were defined, i.e. nocturia, nocturnal incontinence and nocturnal polyuria (NP), and patients with or without NP were analyzed. RESULTS: With a majority of female patients 85% and a mean age of 74.3±5.96 years, a high incidence of nocturia (76%) was observed. NP was associated with nocturia in 56 patients (86%). In the three groups, the maximum bladder capacity and mean micturition volume were statistically higher during the night. Patients with nocturia or nocturnal incontinence associated to NP presented with a higher nocturnal maximum bladder capacity and mean micturition volume. A higher nocturnal post-void residual (PVR) was observed in patients with Nocturnal Incontinence associated with NP (P=0.03). Patients without NP presented significantly higher diurnal results. CONCLUSIONS: Nocturnal LUTS in older people is the result of a high nocturnal urine production related to NP with a higher nocturnal bladder capacity. The analyses of micturition, incontinence and PVR, and the accurate evaluation of the presence or absence of NP seems to be the key point for a better therapeutic choice in patients suffering by Nocturnal LUTS.

Circadian Variation in Post Void Residual in Nursing Home Residents With Moderate Impairment in Activities of Daily Living.

BACKGROUND: Despite the conflicting evidence about postvoid residual (PVR) and its variation in time and corresponding voided volume (VV), studies with urinary diaries and systematic measurements of PVR after each void have never been conducted in nursing home (NH) residents. OBJECTIVE: To describe the circadian rhythm of PVR and residual fraction (RF, the net quantity of PVR) and to identify the time window with the highest PVR and RF. DESIGN, SETTING, AND PARTICIPANTS: A multicentre prospective study conducted between 2014 and 2015 in 5 Belgian NHs. A convenience sample of cognitively intact residents completed a 24-hour frequency volume chart with PVR. RESULTS: Participants (n = 73) had a median age of 84 years (interquartile range 82-89) and moderate impairment of activities of daily living; 69% were women. In residents with nocturia, mean PVR was higher during the night [45 mL (26-80)] than during the day [36 mL (18-61)]. In residents without nocturia no difference was detected. In spite of the variation between diurnal and nocturnal VV and PVR in residents with nocturia, all residents emptied their bladder as effectively during daytime as during nighttime [mean RF = 20% (12-32)]. Maximum PVR and RF in residents with nocturia (n = 57) showed a circadian variation. The highest PVR and RF were found during the day. The PVR and RF of the first morning void were an indicator of the maximum nocturnal PVR and RF. CONCLUSIONS: PVR and VV should be measured in NH residents during the waking hours (first morning void excepted) to detect the clinically relevant maximum PVR and RF.

Clean Intermittent Self-Catheterization as a Treatment Modality for Urinary Retention: Perceptions of Urologists.

PURPOSE: Clean intermittent self-catheterization (CISC) is now considered the gold standard for the management of urinary retention. In the literature, several articles on patients' perspectives on CISC and adherence to this technique have been published. No studies have yet explored the points of view of professional caregivers, such as nurses and doctors. The aim of this study was to explore the opinions of urologists about CISC and to evaluate the need for dedicated nurses specialized in CISC through a self-administered questionnaire. METHODS: A questionnaire was developed to explore the opinions of professional caregivers about self-catheterization and to evaluate the need to provide nurses with specialized education in CISC. Questionnaires were sent to 244 urologists through email. We received 101 completed questionnaires. The response rate was 41.4%. RESULTS: Hand function, the presence or absence of tremor, and visual acuity were rated as the most important determinants for proposing CISC to a patient. Twenty-five percent of the urologists reported that financial remuneration would give them a greater incentive to propose CISC. The lack of dedicated nurses was reported by half of the urologists as a factor preventing them from proposing CISC. A meaningful number of urologists thought that patients perceive CISC as invasive and unpleasant. Although most urologists would choose CISC as a treatment option for themselves, almost 1 urologist out of 5 would prefer a permanent catheter. CONCLUSIONS: This questionnaire gave valuable insights into urologists' perceptions of CISC, and could serve as the basis for a subsequent broader international study. Further research should also focus on the opinions of nurses and other caregivers involved in incontinence management. Apart from financial remuneration, it is also clear that ensuring sufficient expertise and time for high-quality CISC care is important. This could be a potential role for dedicated nurses.

Video Urodynamic Study in Female Adults With Air-filled Catheters: A Health-care Training Video.

OBJECTIVE: To take the first step toward standardization of UDS with air-filled catheters, we present a video documenting a procedure for performing video UDS with air-filled catheters in female adults. According to The International Consultation on Incontinence (ICS), the aim of urodynamic studies (UDS) in clinical practice is to evaluate a patient's lower urinary tract function with at least 1 complete and representative filling-voiding-post-voiding cycle by testing with relevant pressures and flowmetry.1 International guidelines state that UDS is preferably performed with fluid-filled catheters.2,3 However, although air-filled catheters are widely used, further research is needed before these catheters can be recommended for routine clinical use.4 To our knowledge, no guide on how to perform UDS with air-filled catheters has been published. METHODS: The UDS was conducted according to local protocol. The ICS recommendations mentioned above were used as a template for this protocol. Intravesical, intraurethral, and abdominal pressure were measured. The cysto-urethrometry filling cycle and pressure-flow study were performed in sitting position. Fluoroscopy was performed during filling and voiding phase at fixed points. Before starting the filling cycle, the patient was verbally instructed with visual aids (Fig. 1) to report bladder sensation. Filling rate was 10% of the largest voiding flow rate reported on the frequency volume chart. Initial baseline pressure was measured, and a cough pressure response test was performed. RESULTS: Our procedure for video UDS with air-filled catheters in a female adult was demonstrated in an instruction video. CONCLUSION: An instruction video on a standardized UDS with air-filled catheters in female adults is presented to take the first step toward standardization and for the benefit of health-care workers performing such tests.

Older People's Preferences for Side Effects Associated with Antimuscarinic Treatments of Overactive Bladder: A Discrete-Choice Experiment.

INTRODUCTION: Understanding the importance older people attribute to the different side effects associated with oral antimuscarinic treatments for overactive bladder (OAB) could help inform prescribers, healthcare policy makers and the drug industry. OBJECTIVE: Our objective was to quantify the importance of the most prevalent cognitive and side effects of oral antimuscarinic treatments for OAB in older people. METHODS: We conducted a discrete-choice experiment (DCE) with the assistance of an interviewer with community-dwelling and hospitalized older people aged >65 years. The DCE involved two hypothetical drugs for imaginary OAB, with three levels of four side effects for each drug, and the International Consultation on Incontinence Questionnaire-Overactive Bladder and EuroQol 5-Dimensions (EQ-5D) questionnaire were also administered. Data were analysed using a conditional logit model. RESULTS: In total, 276 older people participated in the study. The median age was 75 years (interquartile range [IQR] 69-80), 63% were women and 21% had OAB syndrome. The most unwanted side effect in the choice of antimuscarinics for OAB was severe cognitive effects, followed by severe constipation, severe blurred vision, severe dry mouth, moderate cognitive effects and moderate constipation. Severe cognitive effects were at least 1.7 times as important as severe constipation. Exploratory subgroup analysis showed that none of the attributes was found to be significant in people who scored as anxious or depressed on the EQ-5D, and preferences about cognitive effects, constipation and blurred vision were equal in people with and without OAB. CONCLUSION: Older people attribute more importance to loss of cognitive function as a possible side effect of antimuscarinic treatment than to the three most prevalent possible side effects of this treatment.

Urodynamic studies in children: Standardized transurethral video-urodynamic evaluation.

OBJECTIVE: The aim was too demonstrate standardized video-urodynamic study (VUDS) in children using a transurethral catheter and pressure transducers. METHODS: Data necessary to obtain urodynamic evaluation of bladder sphincter function were gathered by concomitant measurement of bladder, urethral, and abdominal pressure. A 7F transurethral triple-lumen water-filled catheter was used for measuring the bladder and sphincter pressures and a water-filled 8F catheter connected to a pressure transducer was inserted into the rectum for pressure measurement. Cystometry was combined with fluoroscopy, providing simultaneous voiding cystourethrography information. Detrusor activity, bladder sensation, capacity, and compliance were measured during filling cystometry. Voiding cystometry consisted of recording pressures in the bladder sphincter and abdomen with simultaneous urinary flow measurement. RESULTS: Transurethral VUDS was safely and easily performed in a clinical setting adapted to children. CONCLUSIONS: A good and reproducible UDS is mandatory for correct therapeutic decisions. A standardized study associated with fluoroscopic assessment is presented in this video.