Biofeedback per le donne anziane
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.
Release Date: January 4, 2008; Valid for credit through January 4, 2009
Credits AvailablePhysicians – maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians – up to 0.25 AAFP Prescribed credit(s) for physicians
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.
Physicians should only claim credit commensurate with the extent of their participation in the activity.
January 4, 2008 — In older women with urge urinary incontinence (UI), biofeedback (BFB) therapy significantly improved psychological burden, especially in those with a history of depression, according to the results of a study reported in the December issue of the Journal of the American Geriatrics Society.
“The goal of the current study was to assess the effect of BFB on psychological burden in older women with urge UI and the potential effect of depression on the response,” write Stasa D. Tadic, MD, from the University of Pittsburgh in Pennsylvania, and colleagues. “Because depression is associated with ‘learned helplessness,'” which incontinence might augment, it was further hypothesized that the psychological burden of urge UI is greater in older women with a history of depression and that subjects with a history of depression might respond better to BFB, because it improves their perception of helplessness by teaching them how to control the urgency and, in the process, substantially reduces incontinence as well.”
In this secondary analysis of an ongoing trial at an academic medical center, 42 community-dwelling women at least 60 years of age with urge UI received BFB and behavioral training in urge suppression during an 8-week intervention. Study endpoints were frequency of urge UI on a 3-day bladder diary, psychological burden evaluated with the Urge Impact Scale (URIS-24) total and subscale scores, history of depression, and depressive symptoms on the Mental Component Subscale (MCS) of the Medical Outcomes Study 36-Item Short Form Survey (SF-36). Age and chronic conditions were considered as covariates.
BFB was associated with improvements in UI (by 45%; P = .001) and psychological burden (P = .001 for a total URIS-24 score and for all 3 subscales; P = .01 for the MCS of the SF-36). The magnitude of UI improvement was similar for those with and without a history of depression, but improvement in psychological outcomes was twice as great in those with a history of depression, especially on the perception of control subscale. Improvement was not related to depressive symptoms at baseline.
“In older women with urge UI, BFB significantly improves psychological burden, especially in those with a history of depression, in whom psychological burden is linked to change in perception of control,” the study authors write. “Psychological factors are relevant outcome measures for UI, and these data suggest that focusing on UI frequency alone may have underestimated BFB’s efficacy and additional therapeutic benefits.”
Limitations of the study include sample limited to community-dwelling women; analysis of the effect of depression not an original trial objective, resulting in less than optimal evaluation of depressive symptoms; lack of specificity of the SF-36; inability to exclude the effect of the therapeutic role played by the BFB technician rather than the BFB itself; and interim analysis of an ongoing study with small sample size.
“These findings suggest that it may be worth screening patients with urge UI for a history of depression, as suggested by others, especially if therapy for depression is found to further enhance the response to BFB,” the study authors conclude. “Further studies will be necessary to address these possible implications.”
The National Institutes of Health and the John A. Hartford Foundation University of Pittsburgh Center of Excellence funded this study. Two of the study authors have disclosed various financial relationships with Laborie Medical Technologies, Aventis, and Merck. The remaining study authors have disclosed no relevant financial relationships.
J Am Geriatr Soc. 2007;55:2010-2015.
Learning Objectives for This Educational ActivityUpon completion of this activity, participants will be able to:
- Describe the effect of biofeedback therapy on symptoms and psychological burden of urge urinary incontinence in older women.
- Describe the effect of biofeedback therapy on the psychological burden of urge urinary incontinence in older women with a history of depression.
Clinical ContextUrge UI is characterized by abrupt urinary leakage generally preceded by urgency and is the most difficult and prevalent form of UI in elderly women, creating considerable psychological burden including depression. BFB has been suggested as a first-line therapy for urge UI and can assist in strengthening of pelvic floor muscles to respond to sudden urgency (urge suppression strategy). The authors hypothesized that the effect of BFB may be greater in women with urge UI with a history of depression because of its beneficial effect on psychological burden.
This is a secondary analysis of an ongoing study examining the mechanism of response to BFB in older women with urge UI to evaluate the physical and psychological benefits of 8 weeks of treatment.
- Women 60 years or older who were independent and community dwelling with at least 2 episodes of urge UI per week for at least 3 months despite treatment were recruited through advertisements.
- A 24-hour voiding diary and pad test were completed as was a Mini-Mental Status Examination (MMSE).
- Excluded were those with an MMSE score of 24 or higher, history of bladder cancer or other serious pathologic disorder, or comorbid serious medical conditions.
- Baseline evaluation included physical examination, uroflowmetry, postvoid residual urine, and urodynamic assessment.
- Women were instructed to continue the medications they had been taking for urge UI.
- A 3-day diary documenting times and amounts voided or leaked, circumstances of UI, and number of episodes of urge UI were considered measures of urge UI.
- The 3-day diary was completed at the end of the 8-week study.
- A history of depression was defined as at least 1 previous episode that a physician or psychiatrist diagnosed and treated with an antidepressant.
- The number of chronic conditions from 0 to 10 was recorded for persons older than 65 years with criteria of the National Health Interview Survey.
- The psychological burden of disease was assessed with the URIS-24 with scores from 24 to 120 and higher scores indicating better quality of life.
- 3 domains of the URIS-24 were assessed: psychological burden, perception of personal control, and self-concept.
- The MCS of the SF-36 was used as a proxy measure of depressive symptoms with a cutoff score of 48.
- BFB therapy consisted of anorectal BFB with verbal instructions and behavioral techniques such as urge suppression and pelvic floor exercises.
- Women attended 4 biweekly clinics at weeks 1, 3, 5, and 7 with home practice in between visits and were monitored with bladder diaries.
- 42 women were recruited, of whom 12 had a history of depression with a diagnosis made 1 to 15 years before, and 9 women were still taking antidepressants.
- Mean age was 73 years, mean MMSE score was 29, mean number of chronic conditions was 3, and mean number of incontinence episodes in the 3-day diary at baseline was 13.
- Women with a history of depression scored significantly lower on the MCS of the SF-36 and had more chronic conditions at baseline.
- BFB improved all urge UI physical and psychological outcome measures significantly: frequency of incontinence by 45% (P< .001), psychological burden by 15.8 points (22.4%), and the MCS of the SF-36 by 6.1%.
- Improvement in frequency of urge UI was similar in those with and without a history of depression.
- The improvement in psychological measures was twice as great in women with a history of depression.
- In particular, the subscale for perception of personal control showed a greater improvement in women with a history of depression vs those without.
- The interaction was seen together with an improvement in symptoms of incontinence.
- The authors suggested that differences in the prevalence of history of depression may explain differences in responses to therapy in women with urge UI.
- The authors suggested that BFB may be more effective than medications, and that women with urge UI should be screened for a history of depression before treatment selection.
Pearls for Practice
- Use of BFB in women older than 60 years with urge UI for 8 weeks is associated with improvement in frequency of UI, quality of life, and psychological burden.
- Improvement in psychological burden of urge UI seen with BFB is greater in women with a history of depression.
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Target AudienceThis article is intended for primary care clinicians, urologists, gynecologists, geriatricians, and other specialists who care for women with urge urinary incontinence.
GoalThe goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.
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Laurie Barclay, MD
is a freelance reviewer and writer for Medscape.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Désirée Lie, MD, MSEd
Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.
Brande Nicole MartinMedscape Medical News 2008. ©2008 Medscape
is the News CME editor for Medscape Medical News.
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.
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