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Continence Coach: Nurses Beware: Don’t “Write off” Sleep-disturbing Voiding
Whether patient, spouse or partner, or yourself, many of us know persons affected by nocturia — ie, sleep-disturbing voiding.1 Its high prevalence is due to the number of causal factors. Numerous studies illustrate the negative impact of sleep disorders, regardless of their causes, on physical and mental performance, speech and memory, and physical and emotional energy, and as such fatigue, weight management, and mental outlook. Sleep problems, including snoring, sleep apnea, insomnia, sleep deprivation, and restless leg syndrome, can be contributing factors. Although insomnia often is related to either pain or depression, nocturia is recognized by researchers as an independent risk factor for compromised sleep quality.2 In fact, nocturia is the leading cause of sleep problems, accounting for slightly more than half (52%) of all self-reported explanations for being disturbed in a list of nearly a dozen reasons.3 Many clinicians long considered nocturia to be a symptom of overactive bladder (OAB), characterized as frequency and urgency of urination and affecting an estimated 33 million adult Americans.4 The definition of OAB continues to incorporate symptoms of nocturia. However, 15 years ago, researchers considered the age-attributable increase in symptoms to be caused by a nocturnal decrease in vasopressin over time rather than sudden bladder contractions of idiopathic origins.5 This helps explain why OAB drugs alone do not combat nocturia all that effectively. Currently, no pharmacological treatment is available in the United States for nocturia.
Urologists and endocrinologists have increasingly supported the non-OAB theory, recognizing urogenital factors also could influence the incidence of nocturia, including symptoms of menopause in middle-aged women and symptoms of enlarged prostate in older men. Although various studies of nocturia indicate men and women are equally likely to be plagued by getting up in the night to urinate,6 the prevalence of nocturia increases more rapidly with age in men than in women.7 Consequently, it is more common among women at a younger age. Gender differences aside, the incidence overall clearly increases with age.
Three years ago, the National Association For Continence8 (NAFC) conducted a nationwide, descriptive, cross-sectional study of the frustrations and effects of OAB and nocturia on middle-aged women 40 to 65 years old. The study compared their lives and experiences to women without OAB or nocturia to understand its impact. We found not only do women with OAB almost always (96%) get up to urinate at night, but also that one in five (20%) typically experiences severe nocturia, necessitating four or more trips to the bathroom during the night. Three in four (78%) have classic symptoms of getting up at least twice to urinate. Nearly one in four (23%) with OAB including nocturia felt somewhat or extremely dissatisfied with current treatment of their symptoms. Of the two thirds (64%) of OAB respondents with nocturia who had sought treatment, half (51%) had discontinued treatment.
The majority (63%) of survey respondents complained that not getting enough sleep throws off their sense of “normalcy.” Women with OAB and nocturia were more likely (28%) to express feelings of insecurity than those without nocturia (20%). The fact that nocturia affects socialization, physical intimacy, and relationships is reinforced several times over by findings from our data. And severe nocturia, or getting up four times or more in the night, steals away more than a person’s physical health. Nocturia clearly affects an individual’s life experiences and thus their personal sense of worth, leaving suffers depressed and mentally fatigued. We haven’t conducted similar quantitative research among men, but we believe anecdotally from daily phone calls and emails to our headquarters that older men are similarly affected, even if they describe the effects differently. Fatigue, lack of sexual interest, and even depression are often concerns. This doesn’t even take into account nocturia’s effects on their partner or spouse, regardless of gender.
More staggering are statistics surrounding the mortalities caused by nighttime toileting by the impaired elderly. In the US, 16% of all Emergency Department visits and almost 7% of all hospitalizations are for fall-related injuries.9 Falls put the elderly in nursing homes if they aren’t already there. The Centers for Disease Control and Prevention (CDC) estimates that falls among older adults cost our nation more than $30 billion in 2010, and this number is projected to double by 2020 due to the demographics of aging.10 Of the 21.8 million persons >15 years old sustaining nonfatal injuries in 2008, 234,000 represented bathroom injuries treated in hospital emergency departments; 80% of these bathroom injuries were due to falls, and 23.4% of the injuries were reported to have occurred in the vicinity of the toilet, according to the CDC.10
Until new remedies become available, some behavioral practices may make a difference. Limiting fluids 3 hours before bedtime; eliminating caffeine, alcohol, and any diuretics in medications, beverages, and foods; double voiding before bedtime; use of compression stockings; and elevating feet an hour before retiring to bed are worthwhile strategies. Acknowledging nocturia can steer the wise clinician to diagnose what could be a serious causal morbidity, such as cardiovascular disease or diabetes. On the other hand, misdirected pharmacological treatment such as a sleep aid — ie, a quick fix by a primary care provider for a suspected sleep disorder — can lead to higher healthcare costs, adverse events, and drug interactions.11
Nurses beware: Don’t get caught “writing off” nocturia as just a natural part of aging. Give it your uncompromised attention.
Dr. Muller is the Executive Director, National Association For Continence (NAFC). The NAFC is a national, private, nonprofit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence.
This article was not subject to the Ostomy Wound Managment peer-review process.
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9. Facts about Falls. Available at: www.fallprevention.org/pages/fallfacts.htm. Accessed April 30, 2013.
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