A new study of Medicare patients shows that having a diagnosis of overactive bladder is a risk factor for falls (Jayadevappa 2015). The investigators analyzed over 30,000 Medicare patients, using claims data from a random sample of 5% of the Medicare population between 2006 and 2009 and ICD diagnosis codes for overactive bladder (OAB), functional urinary incontinence, urinary incontinence, urinary frequency, urgency urination, nocturia, or stress urinary incontinence. After adjustment for several variables, the risk for falls in those with a diagnosis of overactive bladder was 1.30. The only other variable that was a stronger predictor of falls was a history of previous falls (odds ratio 1.7).
Those who received treatment for overactive bladder had a lower risk of falls compared to those not treated (OR 0.92). However, we recommend caution in jumping to a conclusion that treatment reduces fall risk. Only 10% of patients with a diagnosis of overactive bladder received treatment. The decision whether to use medications for overactive bladder likely takes into account multiple clinical factors that are unlikely to be accounted for in claims data.
We would add a few further words of caution about treatment. Not only are anticholinergic drugs a risk factor for delirium and cognitive impairment in the elderly, but anticholinergic drugs themselves are also a risk factor for falls (Rudolph 2008). And in our February 10, 2015 Patient Safety Tip of the Week The Anticholinergic Burden and Dementia we noted a study showing an association between anticholinergic burden and development of dementia (Gray 2015). In that study bladder antimuscarinic drugs were one of the top three categories of anticholinergic drugs prescribed. And even more recently a study has noted an association between anticholinergic drugs and pneumonia in community-dwelling patients age 65 and older (Paul 2015).
Actually, it should not really come as a surprise that an overactive bladder is a risk factor for falls. Is it biologically plausible that overactive bladder would be a risk factor for falls in the elderly? Certainly. Patients with overactive bladder might hurry when they get the urge to void, increasing their risk of tripping and falling. And if they have episodes of incontinence they risk falling from slippery surfaces. They also may get the urge to void at night, with increased risk of falling in poor lighting. A previous study (Vaughan 2010) had shown an association between nocturia and falls and patients with OAB symptoms are likely to have nocturia. And, while most patients have an idiopathic OAB, the symptoms of frequency, urgency and precipitate micturition are also seen with neurogenic bladder accompanying a host of neurological conditions, many of which are associated with motor or balance dysfunction that may also be fall risk factors.
In our December 22, 2009 Patient Safety Tip of the Week Falls on Toileting Activities we noted that almost half of falls in hospitals occur during activities related to toileting, most occurring when attempting to go from bed or chair to the bathroom or returning from the bathroom rather than when getting on or off the toilet. And, not surprisingly, most of those falls occur at night.
While poor lighting at night is a major contributor to falls, staffing levels during evenings and nights may also contribute. In our December 22, 2009 Patient Safety Tip of the Week Falls on Toileting Activities we noted a study showing that most falls related to toileting activities occurred in patients already labeled as being at high risk for falls (Tzeng 2010) and another study (Krauss et al 2008) showing poor staff compliance with toileting schedules, even during a period of a targeted intervention.
We suggested that perhaps the toileting needs of our patients might be better met by aides or staff other than nursing. Perhaps a specially-trained aide or team could work from 10 PM to midnight or 9 PM to 11 PM and just focus on ensuring all patients at high risk for falls get appropriate assistance toileting before they go to sleep. Keep in mind that such attention to toileting is also important in the patient at risk for delirium. Note that we have also mentioned the gender issue on several occasions. Many studies have identified male sex as a risk factor for falls. We dont know if that is due to macho vs. modesty. If it is the latter, then male patients may be hesitant to ask a female nurse to help them to the bathroom. So consider having some male aides on your team to assist male patients with toileting as well.
Patients with OAB symptoms, once they get the urge to void, often need to void right away. So it should be no surprise that an inpatient with OAB wont wait for a response to the nurse call button and will try to get to the bathroom by him/herself. So at least for male inpatients with OAB one should keep a hand-held urinal within reach at the bedside as long as they have the cognitive capacity to use it. Some females might also be able to utilize a bedpan by themselves before a nurse arrives for assistance.
So here are some of the things you should be doing to reduce the risk of falls in your patients who have symptoms of overactive bladder:
Some of our prior columns related to falls:
Jayadevappa R, Chhatre S, Newman D, Wein A. Association between overactive bladder and risk of falls among Medicare elderly fee-for-service patients. American Urological Association 2015; Abstract PD24-09
Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med 2008; 168(5): 508-513
Gray SL, Anderson ML, Dublin S, et al. Cumulative Use of Strong Anticholinergics and Incident Dementia. A Prospective Cohort Study. JAMA Intern Med 2015; Published online January 26, 2015
Paul KJ, Walker RL, Dublin S. Anticholinergic Medications and Risk of Community-acquired Pneumonia in Elderly Adults: A Population-based Casecontrol Study. J Am Geriatr Soc 2015; 63(3): 476-485
Vaughan CP, Brown CJ, Goode PS, et al. The Association of Nocturia with Incident Falls in an Elderly Community-Dwelling Cohort. International Journal of Clinical Practice 2010; 64(5): 577-583
Tzeng H-M. Understanding the Prevalence of Inpatient Falls Associated With Toileting in Adult Acute Care Settings. Journal of Nursing Care Quality 2010; 25(1):22-30
Krauss MJ, Tutlam M, Costantinou E, et al. Intervention to Prevent Falls on the Medical Service in a Teaching Hospital. Infection Control and Hospital Epidemiology. Volume 29, Issue 6, Page 539545, Jun 2008
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