Healthy Aging Below the Belt Mind over Matter: Healthy Bowels, Healthy Bladder Heidi Brown, MD, MAS University of Wisconsin-Madison School of Medicine & Public Health [email protected]

Disclosures, Funding, Support WI Multidisciplinary K12 Urologic Research Career Development Program (NIH K12DK100022-2)

Community-Academic Aging Research Network (CAARN)

http://www.amazon.com/Everyone-Turtleback-Library-Binding-Edition/dp/0613685725

Overview • Why is incontinence important? • How do we ensure that people with incontinence have access to effective solutions? • How do we expand the reach of these solutions?

Why is incontinence important?

“Would you stop leaving incontinence leaflets lying about! I’ve told you, I don’t have a problem!”

I had a lot of leakage, and it was an all day process. I had to clean up at work and change clothes. It was a big joke for people – where’d you get those clothes, you know? - Ellen, age 63

At the end, before I had my surgery last May, I couldn't go any place. I was stuck in the house. I was completely raw meat down there. I was home bounding myself because the urgency was more than I could handle. I didn't want to go out and have an accident. - Mary, age 56

These ladies are not alone.

18 million adult women in the US have urinary incontinence.

• 25,000 women

http://www.clickhole.com/article/we-put-700-red-dots-map-947

More than half of women 65+ have urinary incontinence.

Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. National Center for Health Statistics. Vital Health Stat 3(36). 2014. http://lowres.cartoonstock.com/health-beauty-urinary_incontinence-urine_infections-water_infections-toilet_breaks-loo_breaks-mgdn861_low.jpg

And it isn’t just urine…

1 in 5 women over age 45 have accidental bowel leakage. IBS

BOWEL DISTURBANCE

MENOPAUSE

DM OBESITY

UI

Brown et al. Int J Clin Pract, November 2012, 66: 1101–1108.

CHILDBIRTH INJURY

I think I have it under control. I'm keeping my secret… I've said to my daughter, who does ask some questions, make sure there's extra toilet paper, you know, when I'm here. I just say I use more toilet paper than a lot of people to cleanup, you know? Well, the older I get, you see, the more I think maybe I don't ever have to tell them. I could have a stroke or a heart attack, they'll never know, you know? Just quietly die. - Kim, age 56 Unpublished focus group data, 2014.

And it’s not just women…

http://en.wikipedia.org/wiki/Desi_Arnaz#mediaviewer/File:Lucy_desi_1957.JPG

40% of men and 60% of women 65+

Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. National Center for Health Statistics. Vital Health Stat 3(36). 2014.

Incontinence is prevalent...

http://jokeallucan.blogspot.com/2013/06/theyre-adult-diapers-in-thong-i-told.html

… and it’s expensive. On average, a woman with urinary incontinence spends $750 per year out of pocket for incontinence management… …and she would be willing to spend twice that per year to be cured.

Subak et al. Obstetrics & Gynecology. April 2008 (111): 899-907

It’s not just financially costly. Some people will say “I don't travel anymore.” They don't say why, but they don't travel anymore. They don’t dare go out anywhere, out to eat, out to a band concert or whatever, they don't dare go out because they're ... - Gloria, age 76

Unpublished focus group data, 2014.

It negatively impacts quality of life. Ability to do household chores

91

Physical recreation

192

Entertainment activities

167

Travel by car/bus >30 min

200

Participate in social activities

216

Emotional health

218

Feelings of frustration

Severe impact in 368 / 938 39% (36 – 42%)

306

Sexual relations Ability for intimate relationship Affects greatly or very much

Affects somewhat or slightly

Brown et al, Int J Clin Pract, November 2012, 66, 11, 1109–1116.

Does not affect at all

Incontinence increases risk of nursing home referral…

Grover et al., J Am Geriatr Soc. 2010 June ; 58(6): 1058–1062.

…and risk of falls.

Adjusted Odds Ratio

2.5 2 1.5

Continent Incontinent

1 0.5 0

Urge Incontinence Mixed Incontinence Chiarelli et al. Aust J Physiother. 2009;55(2):89-95.

Is incontinence a problem? • • • • •

Prevalent Aging population Impacts QoL Expensive Increases NH referral • Increases falls http://demotivators.to/p/904168/-houston-we-have-a-problem.htm

But there’s good news, too.

http://www.andrewgarvey.com/wizard/characters/Images/Glinda%20the%20Good%20Witch%20of%20the%20North%201.jpg

Incontinence can be treated. • • • • •

Lifestyle / behavior modifications Pelvic floor muscle exercises Medications Devices Surgery

Food and Drug Administration. Information for Patients for POP, www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh.

Overview • Why is incontinence important? • How do we ensure that people with incontinence have access to effective solutions? • How do we expand the reach of these solutions?

If it’s so readily treatable, why is incontinence so prevalent?

I never brought this up to a doctor, male or female. It was too embarrassing, it was too ridiculous. It's like I understand that's silly, but I never wanted to discuss it. And so I don't mention it, they don't notice it, it's my little secret. - Kim, age 56

Unpublished focus group data, 2014.

Care seeking is uncommon. 100

Have sought care (%)

90 80 70 60 50 40 30 20

47%

10

29%

0

Urinary incontinence

Bowel incontinence

Brown et al, Female Pelvic Med Reconstr Surg. 2013 Mar-Apr;19(2):66-71.

They’re not in my office, so where are they?

Cara Tannenbaum, MD, MSc

CONTINENCE ACROSS CONTINENTS DARE TO AGE WELL

Bringing Urinary Continence Promotion to the Community Goals: • Inform that incontinence is NOT a normal part of aging • Raise awareness of different treatment strategies • Teach that improvements, and even cures, are achievable regardless of age

Tannenbaum et al, BMJ. 2013 3:e004135.

Women in workshop were 5 times more likely to report significant improvement in incontinence! Continence Workshop

Control workshop

66% 54%

11% Continence Improved

8% Started pelvic floor muscle exercises

16% 4% Sought care for incontinence

Overview • Why is incontinence important? • How do we ensure that people with incontinence have access to effective solutions? • How do we expand the reach of these solutions?

Will it work in US women?

http://ifrymineinbutter.com/2010/12/11/the-belts-working-for-you-just-because-youre-wearing-it-my-favorite-cheesy-workout-videos/

Can it incorporate bowel continence?

Mission: Adapt an evidence-based urinary continence-promotion program to include both urinary & bowel incontinence education & self-management strategies for independent older US women.

Step One: Assess Community Interest

We can give it a try… but I don’t know about the bowels…

Mind Over Matter; Brain Over Bladder: Tips and Tricks for Maintaining a Healthy Pelvic Floor

Predictions? • “When are you coming back?” • “When do we get to work on what went well and what didn’t?” • “What about making sure we can keep doing this stuff?”

What do US women want?

‘Ick factor’ with the bowels? Mind Over Matter: Healthy Bowels, Healthy Bladder

Step Two: Assemble an Advisory Board

Step Three: Ask the experts – – – – – – –

Bowel continence Physiotherapy / occupational therapy Nutrition Health behavior change Adult education Health promotion Community engagement

Step 4: • Modifications – Structure – Content – Components – Delivery

Modifications: Structure • 1 60-minute workshop 3 90minute workshop sessions (every other week) • Snack break incorporated midway through each session • Group size similar (8-15)

Modifications: Content • How the bladder works how the bladder & bowels work • Similar pelvic floor muscle exercises and fluid recommendations • New info: fiber and stool type • New problem-solving & maintenance • New info: care-seeking tools

Modifications: Components • Self-management packet goal setting incorporated into each session • Symptom and goal tracker booklets • Reminder postcards between sessions • Small group activities incorporated

Modifications: Delivery • Powerpoint Slides Large posters with color handouts to take home • Lecture interspersed with small group activities • Slight language modifications (passing wind passing gas) • Facilitator: anyone with experience in group facilitation who attends training

True/False Quiz @ Start & Finish • • • • • • •

Prevalence? Normal part of aging? Pads/diapers = best way to self-manage? Weight loss helpful? Exercises helpful? Drinking too little worse leakage? Too little fiber constipation or loose stools? Only hope for cure medicine or surgery?

Week 1: Info & Goal Setting • • • • • • • •

Introductions Pelvic Floor 101 (Bowels and Bladder) Pelvic Floor Muscle Exercises Snack: Soluble & insoluble fiber sources Self-assessment: Fiber Fiber and Stool Type Fiber Problem-Solving Small Group Activity Wrap up & goals, trackers

Week 3: Problem Solving & Goal Setting • • • • • •

Welcome back, pelvic floor warm up Urinary Incontinence & Fluid Intake Snack: Soluble & insoluble fiber sources Fluid Problem-Solving Small Group Activity Large Group Problem Solving Wrap up & goals, trackers

Week 5: Problem Solving & Goal Setting & Maintenance Planning • • • • • • •

Welcome back, pelvic floor warm up Large Group Problem Solving Long-term Goal Setting Snack: Soluble & insoluble fiber sources Medical treatment options Care-seeking Small Group Activity Wrap up & goals, trackers

Step Five: • Pilot testing modified workshop

Pilot testing Fall 2015 – Montello – Berlin

B M

Pilot Test Outcomes Workshop Participants: • Symptoms • Care-seeking • Self-efficacy • Acceptability Community Partners: • Feasibility • Acceptability • Perceived value

Step Six: • Modifications based on pilot test findings

Further testing: Spring & Fall 2016

* Oregon * Beaver Dam

* Fitchburg * Milwaukee?

Thank you for your attention!

Please provide feedback • Perceived value of this workshop? • Topic relevant to your community? • What would increase your level of interest in this program? • What would discourage you from this program? [email protected] 301-346-6371 (cell)