An Independent Association Between Urinary Incontinence and Falls in Chronic Benzodiazepine Users

To the Editor: Falls are a considerable health concern, leading to injury, hospitalization, and postfall anxiety in older adults.1 One-third of adults aged 65 and older fall each year, a proportion that rises with age.1 Benzodiazepines and urinary incontinence are established risk factors for falls in older adults, increasing the risk of falls by 57% (pooled odds ratio (OR) = 1.57, 95% confidence intervals (CI) = 1.43–1.72)2 and 45% (OR = 1.45, 95% CI 1.36–1.54),3, 4 respectively. The cumulative risk accrued with the combination of both factors in the same individual remains unknown. The aim of this study was to assess the independent effect of urinary incontinence on the risk of falls in chronic older benzodiazepine users living in the community. This was a cross-sectional analysis of baseline data from a community-dwelling cohort of 303 older benzodiazepine users enrolled in the Eliminating Medications Through Patient Ownership of End Results randomized trial.5 Participants were men and women aged 65 and older with an active benzodiazepine prescription dispensed for at least 3 consecutive months before screening based on pharmacy records. A trained research assistant interviewed participants using a standardized questionnaire that included information on age, sex, history of falls, presence and frequency of urinary incontinence as assessed according to International Consultation on Incontinence Questionnaire (ICIQ) score,6 benzodiazepine dose (lorazepam equivalents), number of prescriptions, and number and nature of comorbidities associated with risk of falls (diabetes mellitus, arthritis, hip or vertebral fracture, heart disease, pulmonary disease, stroke, depression, anxiety, mobility impairment, chronic pain).7, 8 Univariable logistic regression analyses were conducted to determine the relationship between falls and potential risk factors: age, sex, living alone, number of comorbidities associated with risk of falls, mobility impairment, number of prescriptions, benzodiazepine dose, and type of and severity of urinary incontinence (frequency of symptoms). Multivariate models were then constructed to ascertain the magnitude of association between falls and incontinence while adjusting for mobility problems, four or more comorbidities associated with risk of falls, benzodiazepine dose of 3 mg or more (lorazepam equivalents), and eight or more active prescriptions of any type. All analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY). Of 303 participants enrolled, 210 were women (69.3%), 85 (28.1%) reported a history of falls, and 66 (21.8%) reported urinary incontinence. Self-reported urinary incontinence more than doubled the risk of falls in univariable analyses (OR = 2.14, 95% CI = 1.21–3.79). Other variables showing a significant association with falls in this sample were female sex, having four or more medical conditions associated with falls, taking eight or more active prescriptions, mobility impairment, and a dose of benzodiazepine drugs of 3 mg/d or more (Table 1). The association between urinary incontinence and falls persisted when adjusted for comorbidities associated with falls, polypharmacy, and mobility impairment (OR = 1.85, 95% CI = 1.01–3.39). Of the 66 participants reporting incontinence, 27 (41%) reported a history of falls. Incontinence severity was significantly higher in those with falls (mean ICIQ score 10.5 ± 5.5 vs 6.9 ± 3.7, P = .002). A dose-response relationship was observed between frequency of incontinence and falls, with falls occurring in 17% of participants with incontinence only once weekly (n = 3/18), 25% of those with incontinence two to three times per week (n = 3/12), 60% of those with incontinence daily (n = 6/10), and 58% of those with incontinence more than once per day (n = 14/24). No significant associations were detected between falls and type of incontinence (stress, urgency, mixed, other). These results indicate that urinary incontinence nearly doubles the risk of falls in chronic benzodiazepine users, even when other risk factors coexist. This finding suggests a separate and distinct explanatory mechanism linking incontinence to falls other than that exerted by medicines on falls. It has been hypothesized that urinary incontinence increases the risk of falls during the act of rushing to the bathroom or through dysfunctional cerebral pathways or white matter hyperintensities.9, 10 Urinary incontinence is not addressed in the vast majority of existing fall prevention programs. Many simple nonpharmacological and pharmacological treatments are available to control urinary incontinence. Falls and incontinence can ultimately lead to functional dependence and should be prevented. Randomized trials are needed to determine whether the introduction of incontinence management into fall prevention programs decreases the incidence of falls and delays functional decline. This program has received financial support from the Canadian Institutes of Health Research in the form of an operating grant to Dr. Cara Tannenbaum. This study was presented at the Canadian Geriatrics Society 34th Annual General Meeting, Edmonton, Alberta, April 10–12, 2014. Conflict of Interest: The authors have no potential conflict of interest to declare. Author Contributions: Godmaire, Grenier: data analysis and interpretation, editing of initial manuscript, final approval. Tannenbaum: study concept and design, acquisition of subjects and data, data analysis and interpretation, revising the article, final approval. Sponsor's Role: The sponsor played no role in the design, methods, subject recruitment, data collections, analysis, or preparation of paper.

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