Risk factors for mild depression in older women with overactive bladder syndrome-A cross sectional study.

Overactive bladder syndrome (OAB) is a common condition characterized by urgency to void, usually accompanied by frequency and nocturia, with or without urge-urinary incontinence (UUI), in the absence of urinary tract infection (UTI) or an underlying metabolic or pathologic condition [ 1 ]. It is estimated that 16–25% of women have some type of lower urinary tract symptom (LUTS), mainly OAB [ 2 , 3 ]. OAB symptoms increase with advancing age in men and women. In the United States, approximately 35% of women aged 75 or older were found to have OAB [ 4 ]. The impact of OAB is broad and significant, affecting the quality of life of patients in general, as well as their social, emotional, psychological and sexual lives [ 5 , 6 ]. Depression is one of the most common and widespread mental illnesses in the world, and a major contributor to the global burden of disease [ 7 ]. End-of-life depression is a public health problem which is associated with an increased risk of morbidity and suicide. In addition, it is associated with physical and cognitive decline, reduced social life, and greater self-neglect, thereby increasing mortality. [ 8 ]. The prevalence of depressive symptoms in the population over 60 years old may reach 40% [ 9 ]. In older people, depression signs can be highly heterogeneous, and often not noticeable, leading to a high risk of late intervention [ 10 ]. One study shows that 38.3% of postmenopausal women have mild depression [ 11 ]. The relationship between severe depression and overactive bladder symptoms is well established. People with OAB Syndrome are at a greater risk of developing depression than people without the condition. A study controlling for age as a confounding variable found that patients with depression have worse OAB symptoms, and their quality of life is more seriously affected compared to those without depression [ 6 ]. Similarly, Melotti et al. showed a correlation between severe depression and OAB symptoms [ 12 ]. In a study with 2,877 women aged 65 years or older, Sexton et al. found that depression was an important factor to the worsening of OAB symptoms [ 13 ]. However, none of the studies cited conducted a detailed analysis regarding mild depression. In fact, we do not know if there is any association between OAB symptoms and mild depression and what factors are at play. There is a gap in the literature: Is there a correlation between mild depression and overactive bladder symptoms? Could public policies be more effective? And, consequently, could there be better preventive measures to avoid mild depression evolving into severe depression? Risk and protective factors contribute more or less to the etiology of depression depending on their frequency and importance over the course of life [ 14 ]. Establishing whether these factors are associated with overactive bladder requires better-informed clinical management, good diagnostic practices and personalized interventions aimed at improving the quality of life of elderly patients. The aim of this study was to evaluate the clinical and sociodemographic factors associated with mild depression in older women with OAB.

This study involved 260 women with a clinical diagnosis of OAB. Nineteen patients failed to meet the inclusion criteria, 16 of them had severe depression and 3 were unable to answer the questionnaires. Thus, data from 241 patients were analyzed. It was observed that 50% of the patients had no symptoms of depression and 50% had mild depression. The mean age was 67 (64–73) years old. In the group studied, 107 (23.2%) patients were married, 135 (56%) did some type of physical activity, 117 (48.5%) did not finish elementary school, and 87 (37.3%) were obese. As for the obstetric history, the median was five pregnancies and three vaginal deliveries. There were no differences between groups regarding clinical and sociodemographic characteristics. Eighty-six (35.7%) patients had no or low anxiety, 75 (31.1%) had mild anxiety, 61 (25.3%) had moderate anxiety and 19 (7.9%), severe anxiety ( Table 1 ). Frequency (percentage). Median [interquartile 25–75%]. Mann-Whitney U test for continuous data. Chi-square test for categorical data. p<0,05. The univariate logistic regression analysis showed that BMI, fecal incontinence, history of gynecological surgery and anxiety were factors associated with mild depression in OAB patients ( Table 2 ). Variables with p-value <0.20 in the univariate analysis were included in the multivariate regression analysis. **p < .20 Multivariate binary logistic regression with enter method. † p<0.05. After the multivariate analysis, history of gynecological surgery and anxiety were maintained in the final model as independent variables associated with mild depression ( Table 2 ). These findings reveal that older women with a history of gynecological surgery and a GDS-15 score of 2.04 were 1.08 times more likely to develop mild depression compared to older women with no history of gynecological surgery.

Anxiety and history of gynecological surgery are factors associated with mild depression in older women with overactive bladder syndrome. Psychological treatment should be approached as an important adjunct to the treatment of women with symptoms of overactive bladder. This study marks the beginning of a study on mild depression in women with OAB and associated factors. Given the large number of women who undergo annual gynecological surgeries and the high prevalence of anxiety in women with overactive bladder, it is important to have specific public services targeted at preventing the disease and caring for this population.

A cross-sectional study was conducted. We recruited 260 consecutive women with a clinical diagnosis of OAB from the Program for Micturition Dysfunction at the Brasília Health Center (Brazil), from October 2013 to October 2018. The study was approved by the Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília (CAEE-089707.13.8.00000.0030- September, 30 2013). All the patients signed an Informed Consent Form. Participants were eligible for inclusion in the study if they were between 60–80 years of age and had a clinical diagnosis of OAB as defined by the ICS (International Continence Society) [ 1 ]. The exclusion criteria were patients with positive urinalysis and urine culture, patients who had been exposed to irradiation or hormonal therapy in the previous six months, patients with neurological diseases, patients using anticholinergic drugs, calcium antagonists, b-antagonists, or dopamine antagonists, patients with a grading ≥ grade III according to the pelvic organ prolapse quantification system (POP-Q), and those unable to satisfactorily answer the questionnaires and with severe depression. The patients selected were interviewed by a healthcare professional specialized in micturition disorders to obtain the clinical and sociodemographic variables. Possible factors included age, BMI (continuous variable), level of physical activity (active or non-active), fecal incontinence, history of gynecological surgery, systemic arterial hypertension (SAH), Diabetes Mellitus (DM), and presence of anxiety. For the evaluation of depressive symptoms, we used the Geriatric Depression Scale-15 (GDS-15), a scale that had been previously validated to screen mood disorders in older adults. The GDS-15 score as an instrument for screening depression was defined as follows: a score of 0–5 indicated individuals without depression, 6–10 suggested mild depression, and 11–15 revealed severe depression [ 15 , 16 ]. Anxiety was assessed by using the Beck Anxiety Inventory (BAI). The BAI is a previously validated questionnaire, consisting of 21 items that evaluate different anxiety symptoms. Based on the individual's own assessment and perception in the last 4 weeks, the symptoms are classified as minimal when the score varies from 0–10; mild, when it varies between 11–19; moderate, between 20–30; and severe, between 31–63 [ 17 ]. To assess the symptoms of overactive bladder, the International Consultation on Incontinence Questionnaire (ICIQ-OAB), recommended by the ICS, was used, and the higher the score, the greater the symptoms of OAB [ 1 ]. The cutoff values adopted to assess nutritional status, as well as the presence of SAH and DM were in line with the recommendations by the World Health Organization (WHO) [ 18 , 19 ]. Based on a nutritional study using BMI, older adults were classified as follows: underweight when BMI ≤ 18.5 kg/m 2 ; normal weight when 18.5 kg/m 2 < BMI <25 kg/m 2 ; overweight when 25 kg/m 2 ≤ BMI <30 kg/m 2 ), and obese when BMI ≥ 30 kg/m 2 [ 20 ]. Volunteers who were physically inactive were considered sedentary, whereas participants who did physical activities at least twice a week and participated in the exercise programs offered by the primary care network were considered physically active. Gynecological surgery refers to surgery on the female reproductive system. This includes procedures for benign conditions, cancer, infertility, and incontinence [ 21 ]. We performed a sample calculation using the G Power 3.1.9.2 program with data obtained from a pilot study of 15 elderly women without depressive symptoms and 15 with mild depressive symptoms. Including the independent variables separately, i.e., fecal incontinence and gynecological surgery, and using the presence or absence of symptoms of mild depression as dependent variables for the univariate logistic regression, and considering a power of 90% and an alpha error of 0.05, a sample of 229 participants was determined. We added 5% more to account for data loss, totaling 241 participants. The non-normal distribution of the data was confirmed by the Kolmogorov-Smirnov test. The categorical data were presented in terms of frequency and percentage. Non-normally distributed continuous data were presented as median and interquartile range (25–75%). Continuous data were compared between the two groups of older women using the Mann-Whitney U test (mild depression and no-mild depression). Categorical data were compared using the Chi-square test. Univariate logistic regression analysis was used to determine the association between each independent variable and the dependent variable (symptoms of depression). The factors included in the model were age, BMI (continuous variable), physical activity level (active or non-active), fecal incontinence, history of gynecological surgery, SAH, DM, and presence of anxiety (continuous variable). Odds ratios (OR) were calculated for each explanatory variable with 95% confidence intervals. Subsequently, variables that showed a p-value of association of less than 0.20 in the univariate regression analysis were included in the multivariate logistic regression analysis [ 20 ]. The best model was selected based on the procedure of reduction of variables, using the enter method. The significance level considered was 0.05. Data analysis was performed using the Statistical Package for Social Sciences (SPSS), version 16.0. The null hypothesis was rejected for P-values <0.05.