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Of all the geriatric syndromes, many people find urinary incontinence one of the most socially isolating. It's embarrassing, it occurs without warning, and often leaves sufferers and their families with the feeling that, if only the patient were "paying attention," wet episodes could be avoided.
"Elderly people come to me with problems ranging from cancer to their hearts," says Neil Resnick, chief of gerontology at Brigham and Women's Hospital and assistant professor at Harvard Medical School. "But all they say to me is, 'Please, doctor, make me dry.' It's an ego insult. They won't shop, they won't go to church, they won't do anything because of their trouble with bladder control."
A geriatrician by training, Resnick pursued special training in urodynamics to better investigate urinary incontinence. Unexpectedly, he encountered continuing resistance from both funding agencies and ethical oversight boards. Urinary incontinence was so completely identified with aging and dementia that no one thought it was abnormal in the elderly. "The summary statement on our first grant questioned the value, interest, or utility of studying questions such as these in a population this old," Resnick recalls. "The reviewers took the step of filing an ethical objection to the study. They said 'How can you involve normal elderly people in this study and subject them to detailed urodynamic testing? Everyone knows that the elderly have physical and cognitive problems that make them wet, and your study will only prove it.' But we knew that nobody had ever looked at this problem."
And he was convinced that there was much more to the incontinence story. He was particularly interested in why some demented patients were able to stay continent, while so many others were wet. Most researchers had tended to look to lost bladder control as the root cause of urinary incontinence. But Resnick found that while nearly all immobile demented patients were incontinent, only half of mobile demented patients were, suggesting that there was much more to incontinence than defects in the urinary tract.
Resnick's team also found that "simple" cases of incontinence frequently included a cause that had never before been recognized. Further studies showed that this condition-termed DHIC, or detrusor hyperactivity with impaired contractility-was actually the single most common cause of incontinence. "As it turned out, incontinence was even more multifactorial than we had thought," Resnick says, "because we had been so focused on finding a single cause in the urinary tract."
Despite resistance from doubtful funding agencies and review boards, research on DHIC eventually demonstrated that different types of bladder dysfunction were associated with distinctive cellular abnormalities. This was a dramatic step forward in understanding and suggesting treatment strategies for a condition that, incidentally, affects some 15 million Americans. Preliminary results from Resnick's latest work call into question our entire understanding of the role of the urinary tract in geriatric incontinence.
The repercussions of Resnick's study are widely felt and appreciated among older nursing-home residents. Legislation enacted by Congress in 1992 requires that all nursing homes assess and treat geriatric incontinence according to a strategy he and his colleagues developed. No longer would incontinence be summarily dismissed as a foregone conclusion.
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