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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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