The main objective of this study was to analyze the factors associated with urinary incontinence (UI) among older adults living in nursing homes (NHs) in Central Catalonia (Spain). Secondary objectives were: 1) to estimate the prevalence of UI and its types; 2) to estimate the proportion of NH residents receiving behavioral strategies for continence care.

Cross-sectional study conducted in 5 NHs of the Osona county from January to March 2020. The OsoNaH project (“Urinary Incontinence and Sedentary Behaviour in Nursing Homes”) was registered in Clinical Trials. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) standards for cross-sectional studies were followed (1).
Residents aged 65+ permanently living in the NHs were selected, excluding those who were hospitalized, in a coma or palliative care. Section H of the Minimum Data Set MDS, version 3.0, was used to assess UI, fecal incontinence (FI), other bladder/bowel conditions, and behavioral strategies (e.g., bladder training, scheduled toileting, prompted voiding) during the previous 5 days. The Spanish-validated International Consultation on Incontinence Questionnaire Urinary Incontinence–Short Form (ICIQ UI-SF) was applied to the residents with cognitive capacity to respond to questionnaires. The incontinent group was classified as having any amount of involuntary leakage of urine according to the MDS and/or ICIQ-SF. Both instruments were used to classify UI types, i.e. stress, urgency, mixed, or functional (due to cognitive and/or mobility impairments) UI.
Independent variables included sociodemographic (age, gender, months of institutionalization, level of education and marital status) and health-related information (chronic conditions, tobacco and alcohol use, urinary tract infections in the last 30 days, delirium, ulcers as well as unintended weight loss, falls, bone fractures and hospitalizations in the last year). Activities of daily living (ADL), frailty and mobility were assessed with the modified Barthel Index, Clinical Frailty Scale and Rivermead Mobility Index, respectively. Furthermore, the Short Physical Performance Battery (SPPB) was applied, and the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) scale was used to screen individuals at risk of developing sarcopenia. Cognitive status was assessed with the Pfeiffer scale. Sedentary behavior (SB) was assessed with the ActivPAL3 activity monitor for 7 consecutive days. The consumption of liquids (water and drinks) and types of drinks was collected over a 24-hour period. Drugs were collected and active substances were classified according to the Anatomical Therapeutic Chemical code; anticholinergic activity was calculated with the Anticholinergic Risk Scale. 
Descriptive, bivariate (Chi-square, Fisher’s Exact or the linear Chi-square tests), and multivariate (logistic regression) analyses were used to analyze results.

Overall, 185 NH residents were recruited, but 53 were excluded: 35 resident’s legal guardians refused, 6 residents refused participation, 5 under 65 years of age, 4 (2.1%) resident’s legal guardians did not answer, 2 residents were hospitalized and 1 did not live permanently in the NH. Therefore, the final sample consisted of 132 subjects (82.6% women), mean age of 85.2 (SD=7.4) years. 
In the bivariate analysis, most SB variables (except number of SB bouts >60 min and absolute time in SB) had p-value lower than 0.001. However, they presented more than 20% missing data, and none remained in the final model. Furthermore, UI was significantly associated (p<0.05) with diagnosed dementia, depression, visual deficit, digestive disease, group S drugs, anticholinergic medication, nocturia, risk of sarcopenia, physical performance, cognitive impairment, malnutrition, frailty, ADL limitations and FI.
In the multivariate analysis (Table 1), moderate-severe cognitive impairment (OR=4.44, p=0.003), anticholinergic activity (OR=3.50, p=0.004) and risk of sarcopenia using SARC-F (OR=2.75, p=0.041) were significantly associated with UI.
The prevalence of UI was 76.5% (95% CI: 68.60-82.93), being functional UI (45.5%) the most common type, followed by urgency UI (11.4%), mixed UI (8.3%), undetermined (8.3%) and stress (3.0%). Eight (6.0%) residents reported having UI when the proxy respondent was not aware of urinary losses. Furthermore, 11 (8.3%) residents had UI according to the professional but had not reported experiencing urinary losses themselves. The frequency of dual (urinary and fecal) incontinence was 28.8% (95% CI: 21.8-37.0). Only 2 (1.5%) residents suffered from FI but not UI. 
Only 46.2% of residents received at least one behavioral strategy to prevent or manage their UI, being prompted voiding the only applied method in all cases. Total or partial improvement of the continence status was obtained in more than half (57.4%) of the cases who received this strategy, according to the NH staff perspectives.

•	Cognitive capacity, anticholinergic activity and risk of sarcopenia represented significant associated factors of UI in this sample of NH residents from Central Catalonia (Spain).
•	Those residents with moderate-severe impairment had 4.2 times more proportion of UI than those with normal capacity of slight impairment.
•	NH residents taking drugs with anticholinergic activity had 4.0 times more proportion of UI.
•	Residents presenting with risk of sarcopenia according to SARC-F had 2.8 times more proportion of UI.
•	76.5% of this sample of NH residents from Central Catalonia (Spain) suffered from UI.
•	The most common type of UI was functional UI (45.5%), followed by urgency UI (11.4%).
•	Only 46% of residents received prompted voiding as the only behavioral strategy applied for continence care in the NHs. 
•	Total or partial improvement of the continence status was obtained in approximately 57% of the cases who received prompted voiding.

Cognitive impairment, anticholinergic activity, and risk of sarcopenia were significantly associated with UI in this sample of NH residents. These findings reinforce the importance of reviewing residents' medications to reduce anticholinergic burden. More than 3 out of 4 residents in this sample suffered urinary losses and functional UI (due to cognitive/physical restraints) was highly prevalent. However, a  minority of residents received prompted voiding as a strategy for continence care, but some improvement was perceived by the NH in cases where applied. The results of this study highlight the need to apply mobility and behavioral interventions such as prompted voiding, bladder training or scheduled toileting to prevent or manage UI in NHs.

Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9.

Continence 12S (2024) 101556
DOI: 10.1016/j.cont.2024.101556