Very Poor Glycemic Control Worsens Incontinence-Related Limitations in Older, Diabetic Women
SAN DIEGO—In older women with diabetes and urinary incontinence, very high hemoglobin A1c (HbA1C) levels are associated with patient reports of more severe limitations due to incontinence, according to results reported at the 71st Scientific Sessions of the American Diabetes Association.
However, the data also show that in older women with diabetes, poor glycemic control does not predict the presence or absence of urinary incontinence.
Sei Lee, MD, Assistant Professor of Geriatrics at the University of California in San Francisco, and colleagues determined the relationship between glycemic control measured by HbA1C levels and patient-reported limitations due to urinary incontinence in a large, diverse cohort of older women enrolled in the Diabetes and Aging Study, which is sponsored by the National Institutes of Health. The five-year study is examining medical care and outcomes in roughly 112,000 type 2 patients who are aged 59 years and older and enrolled in the Kaiser Permanente Northern California Diabetes Registry.
Glycosuria has long been recognized as a consequence of hyperglycemia, Dr. Lee pointed out. Prior studies that have examined the relationship between poor glycemic control and urinary incontinence have found no association. These earlier studies, however, included few patients with poor glycemic control and thus have had limited statistical power, he said.
The primary outcome measures in Dr. Lee's study were the presence/absence of incontinence and the severity of limitations due to incontinence. To determine the presence or absence of urinary incontinence, patients were asked: “Do you experience occasional accidental urine leakage?” Limitations due to incontinence were determined by asking “During the past 12 months, how much did the leakage of urine affect your day-to-day activities?” Possible responses included not at all, slightly, moderately, quite a bit, or extremely.
Results from 3,916 older women with diabetes and urinary incontinence showed that HbA1C did not predict the presence or absence of urinary incontinence, after adjusting for age, ethnicity, education, income, parity, diabetes duration, diabetes treatment, co-morbid conditions, and body mass index. “I was somewhat surprised given that several studies have shown that hyperglycemia leads to glycosuria, and we had believed that glcycosuria would lead to incontinence,” Dr. Lee said. “On the other hand, there have been small studies that have found no effect [between glycosuria and incontinence].”
Diabetic women with very poor control, defined as an HbA1C greater than 9 %, were about 50% more likely to be more severely limited by incontinence than women with excellent control, defined as an HbA1C below 6%.
“Thus, HbA1C has to be very high (above 9%) in order to worsen existing incontinence in older diabetic women,” said Dr. Lee, who is also a staff physician at the San Francisco Veterans Administration Medical Center. “For example, let's say that your patient is an older diabetic woman who has hypoglycemia and is also worried about incontinence, and her HbA1C is at 8.5%. ‘Tighter' management of her ‘sugars' may lead to recurrent hypoglycemia. Our study suggests that her HbA1C, although high, won't worsen her incontinence. You really have to be very poorly controlled, [with] an HbA1c of 9% or greater, in order to cause more severe incontinence.”
He also recommended that clinicians routinely query their older female patients about incontinence. “It has long been known that urinary incontinence is more common in older women than in younger women and more common in diabetic than non-diabetic women and that it can severely diminish quality of life. We found that two thirds of women reported some accidental leakage of urine. I heartily endorse the recommendation that older diabetic women be screened for incontinence.”
Dr. Lee said he is now conducting a study to explore the relationship between HbA1C and other patient-centered outcomes such as functional limitations in diabetic women who reside in nursing homes.