Indwelling catheter use in home care: elderly, aged 65+, in 11 different countries in Europe.

Abstract

To describe possible differences/patterns in the use of indwelling urinary catheters (IUC) in Europe.
A prospective, population-based, assessment study.
The target population was 4,455 (random sample of 405 from each of 11 countries) aged 65+ receiving home care.
The clients were assessed by using the Resident Assessment Instrument MDS-HC; epidemiological and medical characteristics of clients and service utilisation were recorded.
The frequency of use of IUC related to the patients' activities of daily living (ADL) and cognitive functioning.
The sample consisted of 4,010 informants: 74% female, with mean age 82.3 +/-7.3 years; men 80.9 +/-7.5 years and female 82.8 +/-7.3 years. A total of 216 (5.4%) clients were using IUC. In Italy 23% were using a catheter compared with 0% in The Netherlands. Catheter use was more common in men than in women (11.5% versus 3.3%). Use of IUC was significantly correlated to certain diseases and symptoms and increase in care burden and formal services. Twenty-six per cent of the informants with indwelling catheters scored three or more on a hierarchical ADL scale (0-6). The clients using IUC in the Nordic countries were less dependent on care than in the other European countries. Models built on multivariate analysis explained 37% of the use of IUC. Tradition and attitudes may explain the differences between the sites.
Catheter use is associated with formal or family care burden. The need for nursing home placement ought to be considered in some cases. A stricter criterion for using IUC may be considered in the southern European countries.

Full text

Page 1

Indwelling catheter use in home care in Europe
377
15. Mannino DM, Brown C, Giovino GA. Obstructive lung dis-
ease deaths in the United States from 1979 through 1993. An
analysis using multiple-cause mortality data. Am J Respir Crit
Care Med 1997; 156: 814–18.
16. Lacasse Y, Brooks D, Goldstein RS. Trends in the epidemiology
of COPD in Canada, 1980 to 1995. COPD and Rehabilitation
Committee of the Canadian Thoracic Society. Chest 1999;
116: 306–13.
17. Soriano JB, Maier WC, Egger P, Visick G, Thakrar B, Sykes J,
Pride NB. Recent trends in physician diagnosed COPD in
women and men in the UK. Thorax 2000; 55: 789–94.
18. Crockett AJ, Cranston JM, Moss JR, Alpers JH. Trends in
chronic obstructive pulmonary disease mortality in Australia.
Med J Aust 1994; 161: 600–3.
19. Xu X, Weiss ST, Rijcken B, Schouten JP. Smoking, changes in
smoking habits, and rate of decline in FEV1: new insight into
gender difference. Eur Respir J 1994; 7: 1056–61.
20. Gold DR, Wang X, Wypij D, Speizer FE, Ware JH, Dockery
DW. Effects of cigarette smoking on lung function in adoles-
cent boys and girls. N Engl J Med 1996; 335: 931–7.
21. Bone CR, Higgins MW, Hurd SS, Reynolds HY. Research
needs and opportunities related to respiratory health of
women. Am Rev Respir Dis 1992; 146: 528–35.
22. Feenstra TL, van Genugten ML, Hoogenveen RT, Wouters
EF, Rutten-van Molken MP. The impact of aging and smoking
on the future burden of chronic obstructive pulmonary disease:
a model analysis in the Netherlands. Am J Respir Crit Care
Med 2001; 164: 590–6.
23. Barendregt JJ, Bonneux L, Van der Maas PJ. The health care
costs of smoking. N Engl J Med 1997; 337: 1052–7.
24. De Groh M, Keiserman M. Tobacco use. In: Respiratory
Disease in Canada (Canadian Institute for Health Informa-
tion, Canadian Lung Association, Health Canada, Statistics
Canada). Ottawa, Ontario: Health Canada, 2001, pp. 11–18.
25. Vilkman S, Keistinen T, Tuuponen T, Kivela SL. Age distribu-
tion of patients treated in hospital for chronic obstructive pul-
monary disease. Age Ageing 1996; 25: 109–12.
Received 20 September 2004; accepted in revised form 9 March
2005
Age and Ageing 2005; 34: 377–381
doi:10.1093/ageing/afi094
Published electronically 18 May 2005
 The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
Indwelling catheter use in home care: elderly,
aged 65?, in 11 different countries in Europe
LIV WERGELAND SØRBYE1, HARRIET FINNE-SOVERI2, GUNNAR LJUNGGREN3, EVA TOPINKOVÁ4,
ROBERTO BERNABEI5
1Diakonhjemmet University College, Box 184, 0319 Oslo, Norway
2STAKES, Lintulahdenkuja 4, PO Box 220, FIN-00531, Helsinki, Finland
3Centre for Gerontology and Health Economics, Karolinska Institute, Crafoords v. 12, S-113 24 Stockholm, Sweden
4Department of Geriatrics, 1st Medical Faculty, Charles University and Institute of Postgraduate Medical Education, Londýnská
15, 12000 Prague 2, Czech Republic
5Via Sabotino 12, 00195 Rome, Italy
Address correspondence to: L. Sørbye. Fax: (+47) 22 451 950. Email: sorbye@diakonhjemmet.no
Abstract
Objective: to describe possible differences/patterns in the use of indwelling urinary catheters (IUC) in Europe.
Design: a prospective, population-based, assessment study.
Setting: the target population was 4,455 (random sample of 405 from each of 11 countries) aged 65+ receiving home care.
Methods: the clients were assessed by using the Resident Assessment Instrument MDS-HC; epidemiological and medical
characteristics of clients and service utilisation were recorded.
Measurements: the frequency of use of IUC related to the patients’ activities of daily living (ADL) and cognitive
functioning.
Results: the sample consisted of 4,010 informants: 74% female, with mean age 82.3±7.3 years; men 80.9±7.5 years and
female 82.8±7.3 years. A total of 216 (5.4%) clients were using IUC. In Italy 23% were using a catheter compared with 0%
in The Netherlands. Catheter use was more common in men than in women (11.5% versus 3.3%). Use of IUC was signifi-
cantly correlated to certain diseases and symptoms and increase in care burden and formal services. Twenty-six per cent of
by guest on May 15, 2011
ageing.oxfordjournals.org
Downloaded from

Page 2

L. W. Sørbye et al.
378
the informants with indwelling catheters scored three or more on a hierarchical ADL scale (0–6). The clients using IUC in
the Nordic countries were less dependent on care than in the other European countries. Models built on multivariate analysis
explained 37% of the use of IUC. Tradition and attitudes may explain the differences between the sites.
Conclusions: catheter use is associated with formal or family care burden. The need for nursing home placement ought to
be considered in some cases. A stricter criterion for using IUC may be considered in the southern European countries.
Keywords: elderly, home care, indwelling urinary catheter, quality of care, care burden, RAI-HC, elderly
Introduction
Urinary incontinence (UI) is a significant cause of disability and
dependency; it is distressing and disproportionately affects older
people [1–3]. The frequency in different samples varies from 15
to 30% depending on the study [4, 5]. About 50% of those who
live at home and receive formal services are incontinent [6, 7].
However, only few studies document the prevalence rates
for indwelling urinary catheters (IUC) in home care. In a popu-
lation study of urinary incontinence in the age group 70–97
years, Molander et al. [8] stated that IUC were not often used.
Smith concluded in a review that the prevalence of IUC was
4% [9], whereas a prevalence rate of 10% was found in Japan
by Gotoh et al. [10]. The complications associated with IUC
cause significant morbidity and mortality [11, 12].
Objective
To find out among the clients receiving home care in
11 European sites: (i) the characteristics of the population
that has an indwelling catheter compared with those that have
not; (ii) the differences in practices between the sites; (iii) the
predictors for indwelling catheters for clients in home care.
Methods
Population
The study was performed in 11 European countries: Czech
Republic, Denmark, Finland, France, Germany, Iceland,
Italy, The Netherlands, Norway, Sweden and the UK.
Home care agencies providing home care services to older
persons living in a defined geographical urban area were
chosen by the partners to represent as well as possible the
practices of each of the countries. In each of the sites, the
randomly selected study population comprised 405 persons,
aged 65 years or over, and of those all together 4,010 sub-
jects were finally enrolled in the study. The mean age of the
participants was 82 years and 74% were female [13].
Data collection
In the present study, we used the data collection performed
by using Minimum Data Set version 2.0 for home care
(MDS-HC 2,0) at the baseline. The MDS assessment con-
sists of more than 300 internationally validated variables or
scales and has good inter-observer reliability [13–15]. Serv-
ice utilisation, physical capacity, cognitive skills and psycho-
social characteristics of the clients were assessed and
recorded by specially trained nurses. Indwelling catheter
was defined as any catheter inserted to ensure urinary drain-
age, including catheters inserted suprapubicly or via the uri-
nary tract. Use of an indwelling catheter was assessed as
‘yes’ or ‘no’. Missing values were interpreted as no use of
IUC.
Statistical analyses
Variables previously known to associate with the use of
indwelling catheters were extracted from the database for
the current analyses, which were then performed using SAS
statistical software (Gary Inc., www.statsoftinc.com). First,
the associates of indwelling catheter use were identified
(chi-square analysis for dichotomised variables and Stu-
dent’s t-test for continuous variables). Then the associates
of catheter use were entered one by one into multivariate
models in clinically meaningful groups. The strongest pre-
dictors for indwelling catheters were entered into the final
model to combine the sites with the clinical factors.
Results
Of the 4,010 persons in the study, IUC was found in
216persons (5.4%) and the variation between sites was 0–23%.
Table 1 shows that IUC was used more often in males
than in females (11.5% versus 3.3%, P<0.0001). Use of
catheters followed different patterns in males compared
with females with advancing age (Figure 1).
Table 2 presents comparisons of clients with and with-
out IUC as to the tested clinical features; it also shows the
type of dependency on services as to the clients with IUC
compared with those without it.
Table 1. Use of IUC by gender and by site among the home
care clients in 11 European countries
n=4,010.
Site
. . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .
Czech Republic428
Denmark 469
Finland 187
France 381 15.0
Germany 607 15.7
Iceland 405
Italy 412 30.7
The Netherlands 198 0
Norway 388
Sweden 246 3.0
UK 289
Overall n (%) 4,010 (100) 119 (11.5) 97 (3.3)
Number
IUC in
males (%)
IUC in
females (%) Overall %
7.8
5.0
2.9
0.6
0.3
2.0
6.2
3.1
1.0
18.5
0
1.4
0.6
1.9
2.1
1.3
2.1
8.7
6.2
1.5
23.1
0.0
2.8
1.2
3.8
216 (5.4)
2.9
6.4
9.5
by guest on May 15, 2011
ageing.oxfordjournals.org
Downloaded from

Page 3

Indwelling catheter use in home care in Europe
379
0
2
4
6
8
10
12
14
16
18
20
<75 75-7980-84 85-89>90
IUC, Males (%)
IUC, Females (%)
Figure 1. Urinary indwelling catheters by gender and age among the home care clients in 11 European countries (n=4,010).
Table 2. Comparison of clinical features and need for help among the home care clients with and without an indwelling
catheter in 11 European countries
n=4,010.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
Diseases
Stroke with hemiplegia n=247
Any type of diagnosed dementia n=514
Multiple sclerosis n=032
Parkinsonism n=200
Any cancer n=321
Urinary tract infection n=201
Renal failure n=129
Symptoms and signs
Difficulties in urinating or urinating three or more times during the night n=525
Worsening of bladder incontinence within past 90 days n=409
Fever n=70
Grade 1–4 pressure ulcers n=296
Terminal prognosis n=32
Decline in mood within past 90 days n=470
Functional capacity
ADL>3 (scale=0–6) n=515
CPS>3 (scale=0–6) n=419
Issues related to quality of life and care-giver burden and use of formal services
Client is alone most of the day n=1154
Does not go out of her/his home n=1421
Informal care-giver feels distressed n=259
Informal care-giver is dissatisfied with provided support n=112
Informal care-giver unable to continue n=184
Use of formal services
No review of the medications within past 180 days n=669
Hospital admission within past 90 days n=698
Visit to emergency room (without hospital admission) n=246
Unscheduled emergent care n=324
Visits of home carer within past 7 days n=1629
Visits of nurse within past 7 days n=1295
Visits of home-help within past 7 days n=1635
Indwelling catheter
inserted n (%)
No indwelling catheter
inserted n (%)
P value

0.0975
0.0001
0.0001
0.0001
0.0001
0.0001
0.2264

0.0001
0.0001
0.0001
0.0001
0.0008
0.0111

0.0001
0.0001

0.0001
0.0001
0.0001
0.0001
0.0001

0.0002
0.0001
0.4229
0.0928
0.0049
0.0001
0.0001
19 (8)
46 (10)
7 (22)
23 (12)
34 (11)
38 (19)
10 (8)
228 (92)
468 (91)
25 (78)
177 (89)
287 (89)
163 (81)
119 (92)

9 (2)
41 (10)
14 (20)
77 (26)
6 (19)
37 (9)
516 (98)
368 (90)
56 (80)
219 (74)
26 (81)
433 (92)

134 (26)
88 (21)

13 (1)
160 (11)
48 (19)
18 (16)
22 (12)

16 (2)
83 (12)
16 (7)
24 (7)
68 (4)
101 (9)
33 (2)

381 (74)
331 (79)

1141 (99)
1261 (89)
211 (81)
94 (84)
162 (88)

653 (98)
615 (88)
230 (94)
300 (93)
1561 (96)
1194 (92)
1602 (98)
by guest on May 15, 2011
ageing.oxfordjournals.org
Downloaded from

Page 4

L. W. Sørbye et al.
380
The explanatory value for the first model consisting of
only the 11 sites was 17%, when all the other sites were
compared with the samples collected from The Netherlands
and Sweden. The explanatory value for the model consist-
ing of diagnoses was 7%, for cognitive and physical func-
tional capacity 23% and for the symptoms 14%. The
combined results are presented in Table 3.
Discussion
The AdHOC Study was designed to compare outcomes of
different models of community care using a structured com-
parison of services and a comprehensive standardised
assessment instrument across 11 European countries [13].
The use of IUC varied from 0 to 23% from site to site and
showed a mean prevalence of 5.5%. These devices were
more often found in men than in women in each of the
sites. Occurrence of catheter use was not higher with
advancing age in females; however, an increase of catheters
was seen in ageing males. The diseases with a relationship to
catheter use were those previously shown in the literature
[11–12]. The tendency to insert catheters in males in older
age groups, with advanced dementia, pressure ulcers and poor
functional ability, were our main findings. This occurred
particularly if the client suffered from cancer, multiple scle-
rosis, or if he or she resided in one of the following three
sites: France, Germany or Italy. The explanatory value for
these findings was 37% (r2=0.37).
The frequency of catheter use accords well with the few
previously estimated figures [9]. The presence of cognitive
decline, more serious than moderate dementia, increased the
risk of receiving a catheter almost two-fold; at the same time
the presence of a diagnosis of dementia ceased being signific-
ant in the multivariate model. Thus, not the disease per se, but
the severity of it, is of importance. At the same time the pres-
ence of severe functional decline increased the risk for receiv-
ing IUC a little over four-fold. The presence of pressure ulcers
almost doubled the risk for catheter use. Multiple sclerosis is
not a prevalent disease in this population whereas cancer is
seen slightly more often. When present, the risk for receiving a
catheter increases 6- and 2-fold correspondingly. More fre-
quent use of IUC in males than in females is most certainly
explained by prostate problems that increase with advancing
age. Unfortunately, questions about urinary retention are not a
part of the MDS questionnaire, and this fact makes it some-
what hard to trace the true cause for inserting the catheter.
Variations from country to country in the prevalence of
catheter use may still partially be explained by the case-mix
of the clients. It is of interest that when adjusting the regres-
sion model for dementia and functional capacity in addition
to diseases, the differences vanished between Nordic coun-
tries, The Netherlands and the UK, representing the north-
ern parts of Europe. The Central European or Southern
European region appeared to host different care patterns or
culture of care compared with those living in the north. One
reason for the difference between the sites in the prevalence
of indwelling catheter use could be habit-based instead of
evidence-based practice. Some of the European countries
really had restricted use of IUC, corresponding to the view
of Ouslander [16]. The predictors for the use of indwelling
catheters among the home care clients in Europe (Table 3)
document a complexity in the problem situation [17].
A study from Switzerland documented that the presence
of a urinary catheter was a predictor of unscheduled services
[18]. In our sample the users of IUC had a urinary tract
infection 6.5 times more often than those without a
catheter. Landi et al. [12] conclude that an uncritical use of
IUC should be considered an indicator of poor quality care.
Pilloni et al. [19] documented that intermittent catheterisa-
tion reduces the urinary tract infection. If one has to use an
indwelling catheter, Robinson [20] specifies that fundamen-
tal principles have to be followed. Even if the consequences
of catheter use are beyond the scope of this cross-sectional/
national analysis, the association between catheters and
informal carers’ care-giver burden is alarming.
Conclusion
The use of indwelling catheters among home care clients in
Europe was most frequent in the oldest males with advanced
dementia and poor physical function. The risk for receiving
catheters was additionally increased if the client suffered from
multiple sclerosis, cancer or pressure ulcers and resided in any
of the following sites: France, Germany or Italy.
Moreover, use of urinary catheters was associated with
increased care-giver burden. More research is warranted to
show whether IUC is predicting long-term care placement
among the home care clients in Europe, and if so, will there
be differences between countries.
Key points
• Use of indwelling catheters was most frequent in the oldest
males with advanced dementia and poor physical function.
• The risk for receiving catheters was additionally increased
if the client resided in France, Germany or Italy.
Table 3. Predictors for IUC among home care clients in 11
European countries
n=4,010. r2=0.3663.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . .
Urinary tract infections
Multiple sclerosis
ADL>3
Male gender
Any type of cancer
CPS>3
Grade 1–4 pressure ulcers
Czech Republic
Denmark
Finland
France
Germany
Iceland
Italy
The Netherlands
Norway
Sweden
UK
Odds ratio 95% CI
6.51
5.89
4.64
3.53
2.23
1.87
1.82
2.48
2.58
2.95
6.08
5.60
2.58
14.0
1.00
3.67
1.00
4.90
3.91–10.8
2.08–16.7
3.10–6.92
2.56–4.87
1.39–3.57
1.26–2.77
1.22–2.72
0.64–9.61
0.64–9.67
0.63–10.6
1.75–21.1
1.65–19.0
0.63–10.6
4.12–47.1
1.00–1.00
0.99–13.7
1.00–1.00
1.30–18.5
by guest on May 15, 2011
ageing.oxfordjournals.org
Downloaded from

Page 5

Indwelling catheter use in home care in Europe
381
• Use of urinary catheters was associated with increased
care-giver burden.
Acknowledgement
We are grateful to interRAI, a collaborative network of
researchers in over 20 countries committed to improving
health care for people who are elderly, frail, or disabled.
Funding
European Commission Vth Framework Programme, con-
tract number QLRT-2000-00002
References
1. Heller BR, Whitehead WE, Johnson LD. Incontinence. J
Gerontol Nurs 1989; 15: 16–23.
2. Gardner J, Fonda D. Urinary incontinence in the elderly.
Disabil Rehabil 1994; 16: 140–8.
3. Shimanouchi S, Kamei T, Hayashi M. Home care for the frail
elderly based on urinary incontinence level. Public Health
Nurs 2000; 17: 468–73.
4. Mohide EA, Pringle DM, Robertson D, Chambers LW. Preva-
lence of urinary incontinence in patients receiving home care
services. Can Med Assoc J 1988; 139: 953–6.
5. Klausner AP, Vapnek JM. Urinary incontinence in the geriatric
population. Mt Sinai J Med 2003; 70: 54–61.
6. Brandeis GH, Baumann MM, Hossain M, Morris JN, Resnick
NM. The prevalence of potentially remediable urinary inconti-
nence in frail older people: a study using the Minimum Data
Set. J Am Geriatr Soc 1997; 45: 179–84.
7. Landi F, Cesari M, Russo A, Onder G, Lattanzio F, Bernabei
R. Potentially reversible risk factors and urinary incontinence in
frail older people living in community. Age Ageing 2003; 32: 194–9.
8. Molander U, Sundh V, Steen B. Urinary incontinence and
related symptoms in older men and women studied longitudi-
nally between 70 and 97 years of age. A population study.
Arch Gerontol Geriatr 2002; 35: 237–44.
9. Smith DA. Evaluation of urinary incontinence. JAMDA, Jan/
Feb 2002, 52–510.
10. Gotoh M, Yoshikawa Y, Hattori R, Ono Y, Ohshima S.
A fact-finding inquiry on urinary management of the elderly in
home care. Hinyokika Kiyo, Acta Urol Jap 2002; 48: 653–8.
11. Smith JM. Indwelling catheter management: from habit-based
to evidence-based practice. Ostomy Wound Manage 2003; 49:
34–45.
12. Landi F, Cesari M, Onder G, Zamboni V, Barillaro C, Lattanzio F,
Bernabei R. Indwelling urethral catheter and mortality in frail
elderly women living in community. Neurourol Urodynamics
2004; 23: 697–701.
13. Carpenter GI, Gambassi G, Topinkova E et al. Community
care in Europe. The Aged in HOme Care project (AdHOC).
Aging Clin Exp Res 2004; 16: 259–69.
14. Morris JN, Fries BE, Steel K, Ikegami N, Bernabei R, Carpenter
GI. Comprehensive clinical assessment in community set-
ting: applicability of the MDS-HC. J Am Geriatr Soc 1997; 45:
1017–24.
15. Morris JN, Fries BE, Mehr DR, Hawes C, Phillips C, Mor V,
Lipsitz LA. The MDS Cognitive Performance Scale. J Gerontol
1994; 49: 174–82.
16. Ouslander JG. Geriatric urinary incontinence. Dis Mon 1992;
38: 65–149.
17. Moore KN, Rayome RG. Problem solving and troubleshoot-
ing: the indwelling catheter. J Wound Ostomy Continence
Nurs 1995; 22: 242–7.
18. Santos-Eggimann B, Cirilli NC, Monachon JJ. Frequency and
determinants of urgent requests to home care agencies for
community-dwelling elderly. Home Health Care Serv Q 2003;
22: 39–53.
19. Pilloni S, Krhut J, Mair D, Madersbacher H, Kessler TM.
Intermittent catheterisation in older people: a valuable
alternative to an indwelling catheter? Age Ageing 2005; 34:
57–60.
20. Robinson J. Fundamental principles of indwelling urinary
catheter selection. Br J Community Nurs 2004; 9: 281–4.
Received 7 January 2005; accepted 10 March 2005
by guest on May 15, 2011
ageing.oxfordjournals.org
Downloaded from