To the Editor:

There is currently no formal recognition by the International Classification of Disease (ICD) system of a Functional Urinary Incontinence (UI) diagnosis. It is thought that the etiology is located outside of the bladder itself; therefore, the incontinence is merely a reflection of a more predominate disorder. The current Functional UI definition includes issues associated with Transient UI (physical weakness, poor mobility/dexterity, environmental impediments, pharmaceuticals, cognitive problems such as delirium and dementia). All are potentially reversible issues EXCEPT for dementia which is an irreversible decline in cognitive functioning. Cognition is included as an integral component in all current UI definitions, including normal detrusor function which involves the concept of voluntarily initiated continuous detrusor contraction.1 I think that it is important to provide a clear distinction between Transient/Reversible UI issues and the Functional UI which is associated with an irreversible decline in cognitive function. UI associated with dementia very clearly differs from transient and other UI etiologies in terms of progression, approaches to treatment, and expected outcome. UI associated with dementia involves the insidious loss of the voluntary component.

I am a continence practitioner in long-term care. My residents with dementia void in almost an instinctual way, without any evidence that they "choose" this activity in any cognitive sort of way. This is not a reflex type of incontinence that lacks sensation. I have seen a very clear expression of discomfort on their faces in the case of significant retention. It is like they feel but they don't really have the ability to respond to the sensation in any way other than with the most basic, instinctual response. I see this evolve as dementia progresses. In fact, the prompted voiding behavioral strategy is specifically designed to provide compensation for the individual's fading ability to respond appropriately to bladder sensations.

Clarification of this diagnosis can trigger development of support for better intervention. How can we distinguish between Urge UI and this instinctual type of UI associated with dementia? Specifically, without the cognitive component, when would the bladder be considered overactive and when is this just a normal detrusor contraction? Are there objective indicators to use to differentiate these types of detrusor responses that could perhaps guide us with antimuscarinic use in residents with dementia? Is this situation significantly different from the voiding patterns displayed by an infant who has not yet developed cognitive bladder awareness? The difference here, as I see it, is that the infant's cortical connections are still forming but in a resident with dementia these connections are being lost. It seems logical to me that electroencephalograms (EEG) as well as the cystometrogram (CMG) may be important research tools when evaluating this type of voiding response. The cortex plays a huge role in the concept of voluntary verses involuntary. In my opinion we need specific guidance on how best to approach the fine line between appropriate assessment and invasion of privacy in the demented resident. What is the balance of risk versus benefit for various invasive strategies? Can consistent prompted voiding that is initiated at the point of early cognitive decline work to maintain continence and perhaps even mobility, perhaps even quality of life? Can technology help us with this behavioral intervention?

Some UI experts have said that addressing the "voluntary" component of UI is sort of like opening a Pandora's Box. Yet the Alzheimer's Association has just reported that there are currently more than 5 million people in the United States living with Alzheimer's dementia. They estimate that someone in America develops Alzheimer's disease every 72 seconds; by mid-century someone will develop Alzheimer's disease every 33 seconds. Because of this fact and the eventual challenges our nation will feel as the baby boomers age, I think that this type of UI should at least be defined.

I am very interested in any and all of your thoughts.

Thank you for your consideration of this concept.

Amendment Proposal: Functional Urinary Incontinence ICD Coding

This is a proposal for consideration of an ICD code for Functional Urinary Incontinence (UI) which is defined as "urinary incontinence associated with leakage of urine related to an irreversible impairment in cognitive functioning."

The International Continence Society (ICS) defines normal detrusor (bladder) function as follows: Normal voiding is achieved by voluntarily initiated continuous detrusor contraction that leads to complete bladder emptying within a normal time span, and in the absence of obstruction. For a given detrusor contraction, the magnitude of the recorded pressure rise will depend on the degree of outlet resistance.

Urinary incontinence is defined by the ICS as: the complaint of any involuntary leakage of urine.

All forms of abnormal detrusor function are included in the ICD coding system, with the exception of urinary leakage caused by cognitive impairment severe enough to result in the loss of volitional control of voiding. This type of UI is most common in settings which provide care for older adults suffering from irreversible forms of dementia. (http://www.merck.com/mrkshared/mmg/sec5/ch40/ch40a.jsp.)

This type of UI differs from other types of UI in terms of progression, approaches to treatment, and expected outcome. With this type of UI the severity reflects the level of impairment in cognitive functioning, and it is the alteration in cognitive function that causes the UI as opposed to a primary problem with detrusor or sphincter mechanisms. Current UI definitions include cognitive function as a necessary component of normal voiding, yet no currently recognized ICD definition recognizes UI without this cognitive component. In earlier stages the behavioral strategy known as prompted voiding has been well studied and found to be effective in decreasing UI in these individuals. This strategy is able to compensate for fading cognition. However, current thinking suggests that even with optimal treatment this type of UI will continue to progress as all voluntary control over bladder function is lost. In its final stage this type of UI is irreversible. Management strategies, at this level, will revolved solely around controlling complications such as urinary tract infection, urinary retention, and skin breakdown.

It is important that this type of UI be formally recognized for 2 reasons: its increasing prevalence and the fact that treatment approaches for this form of incontinence are different than those of other forms of UI. In terms of prevalence and incidence, the statistics are sobering: the prevalence of dementia (the causative factor for Functional UI) doubles every 5 years after age 60 until about age 90. According to statistics recently released by the Alzheimer's Association there are now more than 5 million people in the United States living with Alzheimer's dementia. The greatest risk factor for Alzheimer's disease is increasing age, and with 78 million baby boomers beginning to turn 60 last year, it is estimated that someone in America develops Alzheimer's disease every 72 seconds. By mid-century, someone will develop Alzheimer's disease every 33 seconds. (http://www.alz.org/news_and_events_rates_rise.asp.) Dementia affects 30 to 50% of those older than 85 and is the leading reason for institutionalization among the elderly. Prevalence of dementia among elderly nursing home residents is estimated to be 60% to 80%. Nursing homes are a current focus of Centers for Medicare/Medicaid Services (CMS) continence management, and a comprehensive continence care program in any long-term care facility MUST include appropriate management of incontinence caused by advancing dementia. These residents will not benefit from strategies currently recommended for other types of bladder dysfunction and UI. (See p. 184 of Guidance to Surveyors, http://cms.hhs.gov//manuals/downloads/som107ap_pp_guidelines_ltcf.pdf).

According to statistics provided by the Agency for Healthcare Quality, by 2025 the number of Medicare beneficiaries is expected to reach 69.3 million, representing 20.6% of the US population. Over the same period, those over 80 will comprise the fastest growing segment of our population. Cost-effective healthcare focused on the specific needs of this segment of our population is becoming very important. This importance is fully recognized by David Walker, GAO Comptroller General of the United States (http://www.gao.gov/new.items/d07389t.pdf).

Formal recognition of this type of UI will provide clarification as well as foster further understanding of etiology and cost-effective care.

Jenny Hurlow, GNP, CWOCN

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