Growing old is no fun. But it gets worse when you lose control over your bladder.
For about 15 percent of America's 1.5 million nursing home residents, the solution is a urinary catheter -- a plastic tube inserted into the urinary tract to channel urine into a storage bag where it can be more cheaply and easily managed by the nursing staff.
It's an old technology, and not very elegant. But catheters keep patients dry, and that protects them from slow-healing skin sores. It also reduces odors, preserves dignity and saves the costs of repeated washing, linen changes or diapers.
But catheterized patients are vulnerable to urinary infections, which can be fatal if they spread to the blood or kidneys.
Now, Ohio State University researchers say they have shown for the first time that long-term catheterization can triple the risk of death among nursing home patients.
The study found that the longer patients in the study were catheterized, the greater was their risk of fatal complications.
Dr. Calvin M. Kunin and four colleagues at Ohio State studied 1,540 patients in 13 Ohio nursing homes. Their report was published recently in the American Journal of Epidemiology.
After controlling statistically for other risk factors in the sick and elderly patients they studied, the researchers found long-term catheterization was as much a threat to their lives as cancer, cardiac disease, high blood pressure, diabetes and just plain old age.
Also, "catheterized patients were hospitalized about three times more often, stayed in the hospital three times as many days and received antibiotics . . . about three times longer" than comparable patients who weren't catheterized, the study said.
And that costs Medicare alone more than $344 million a year, the researchers estimated.
Not everyone is convinced by the Ohio State study.
Dr. John W. Warren, head of infectious diseases at the University of Maryland Health System, said catheterized patients are usually sicker than other patients, and those in Dr. Kunin's study may have been hospitalized or died for reasons researchers didn't consider.
Dr. Kunin advocates increased Medicare reimbursement rates to allow homes to buy and use more adult diapers. But the current reimbursement system channels most of its resources to hospitals to cure complications, rather than to nursing homes to help prevent them, he said.
The solution, he believes, may lie in research that would lead to better catheters.
"The bladder mechanism is an exquisite sort of thing," he said. When it's healthy, it can flush out all the urine it has collected, and most bacteria with it. What few organisms remain are successfully fought by the immune system. And when urination is finished, the bladder and the urethra -- the tube leading from the bladder out of the body -- collapse, keeping most new bacteria out.
The insertion of a catheter changes all that.
Besides the drainage tube, the catheter includes a tiny balloon that is inflated inside the bladder to hold the tube in place. But the tube and the balloon also prevent the system from emptying completely.
"So you have urine left behind on surfaces that can't be expelled, and bacteria can grow," Dr. Kunin said.
Antibiotics help, but can't clear all the infection "because the bacteria is still sticking around on that catheter," Dr. Kunin said. The surviving organisms quickly become resistant to the drugs.
What's really needed, he said, is a new catheter design that will allow the urethra to collapse after urination, and which will stay in place without a balloon in the bladder.
But manufacturers want to keep their products inexpensive, so research has been sparse. For now, Dr. Kunin said, nursing home residents and their families must rely on themselves and the nursing home staffs to minimize the risks.
Patients and family members should ask nurses how they can help avoid catheterization or at least shorten its duration.
"I would try every other thing, including frequent attention to clothes and bedclothes," Dr. Warren said. "Behavior modification and medications are sometimes useful."
Adult diapers or, for men, a condom-style catheter that does not require a urethral tube may be options.
"They should realize, however, that there may be times when there is no recourse" to catheterization, Dr. Kunin said.
Once a catheter is in place, Dr. Warren said, patients and family members "should keep asking the physician whether it has to stay in place. Patients have got to be persistent questioners, and the family has to be an advocate for the patient."