Nocturia and Sleep

Nocturia is one of the most common causes of insomnia (Tyagi et al., 2014) and is usually defined as needing to wake up at least two times a night to void (Bliwise, Holm-Larsen, Goble, & Nørgaard, 2015).  Nocturia has been shown to negatively impact health-related quality of life (Tikkinen et al., 2010).  It is a common occurrence in older adults with insomnia, and is significantly related to nocturnal awakening and self-reports of feeling unrested (Zeitzer, Bliwise, Hernandez, Friedman & Yesavage, 2013).  Waking up to void only one time a night is usually considered within normal limits (Asplund, 2005), though, as cited by Tyagi and colleagues (2014), is defined by the International Continence Society as waking at least once nightly to void.  Nocturia may be caused by an overproduction of urine at night, a diminished bladder capacity or both (Asplund, 2005).

Nocturia can occur at any age, but the prevalence of nocturia increases throughout the lifespan (Asplund, 2005).  Obayashi, Saeki and Kurumatani (2015) found a quantitative association between the frequency of night time voids and sleep quality in the general elderly population.  The consequences of nocturia puts people at risk of falls, increased death rate, impaired quality of life (Asplund, 2005), and depression (Asplund, Henriksson, Johansson, & Isacsson, 2004).  Asplund (2005) cites that people with nocturia are also prone to have other issues such leg cramps, abnormal sensation in the legs, and night sweats (Asplund & Aberg, 1992).  They are also at risk of balance issues.  It seems that the ability to return to sleep after nocturnal awakenings is the most distressing symptom (Ohayon, Krystal, Roehrs, Roth, & Vitiello, 2010).  One study found that people with type 2 diabetes who had two or more nocturia events a night experienced more sedentary activity the following day (Morris, Sereika, Houze, & Chasens, 2016).   This should be of significant concern to occupational therapists.

The problem of nocturia and obstructive sleep apnea (OSA) are also closely related.  See this Youtube clip by Barry Krakow (uploaded on October 1, 2009) on why nocturia may occur in someone with OSA: https://www.youtube.com/watch?v=x8DZAHqNj9M

Types of Treatments

Recent research (Tyagi et al. 2014) found that brief behavioral treatment for insomnia (BBTI) can help older people with the insomnia itself or with insomnia with nocturia.  However, Tyagi and colleagues (2014) found that having comorbid nocturia decreased the effectiveness of BBTI and suggested addressing both the nocturia and insomnia to improve the efficacy of BBTI.

As cited by Tyagi’s team (2014), behavioral interventions such as restricting fluid intake, moderate daily exercise, keeping warm in bed, performing pelvic floor exercises, practicing urge suppression techniques, delayed voiding, and education has been shown to reduce nocturia (Burgio et al., 2010; Cho, Lee, Kim, Koo, Kim, & Oh, 2012; Hashim, &  Abrahms, 2008; Soda, Masui, Okuno, Terai, Ogawa, & Yoshimura, 2010).  A general article on urinary incontinence (UI) in an OT magazine published by the American Occupational Therapy Association (Hunjan, & Twiss, 2013) described possible assessments and interventions to help people with this problem from an OT perspective. They described the importance of assessing the patient holistically and thoroughly and to work with other team members such as the physician, nurse, dietician or physical therapist.  Occupational therapists Kunjan & Twiss (2013) described medications, foods and risk factors for UI in general and the need to look at physical, environmental, and behavioral factors when helping someone with continence.  These principles should also apply to the OT treatment of nocturia.  Occupational therapists may become more trained in the area and have joined organizations such as the National Association for Continence (NAFC).  Also see the NAFC for list of medications and other risk factors for nocturia: http://www.nafc.org/nocturia

Some physical therapists also specialize in pelvic floor exercises, continence and women’s health issues (Kassai & Perelli, 2012).  Physical therapist Kathryn Kassai and author Kim Perelli (2012) wrote a comprehensive book, The Bathroom Key: Put an End to Incontinence, on the topic.   The book is primarily aimed towards women but can be helpful to men and has a self assessment, the “Kassai Self- Assessment for Urinary Control” that can be replicated and used by an OT to get a snapshot of a client’s urinary control, nocturia, functional, social & mood status.

Koketsu Nocturia Guideline

  • Obtain a thorough occupational profile of your client (AOTA, 2014). Use an assessment of nocturia such as the Kassai Self-Assessment for Urinary Control (Kassai & Perelli, 2012) for baseline and outcome measures.
  • Keep a diary of fluid and food intake and voids: The NAFC also has a continence diary http://www.nafc.org/diaries/

Consult with the physician and dietician.

  • Consider modification of diet and fluid intake (Hunjan & Twiss, 2013). Consult with a dietician and physician. Consider foods that may irritate the bladder, timing of fluids and volume of fluids.  Some people require an increase in fluid as concentrated urine can irritate the bladder.  For a list of possible bladder irritants from the NAFC: nafc.org/diet-and-exercise/
  • Consider relaxation exercises such deep breathing, mindfulness-based stress reduction exercises.
  • Consider engagement in moderate exercises that the client can perform.
  • If edema is present in the legs, use compression stockings during the day (Asplund, 2005).
  • If there is swelling in the legs, elevate of the legs during the day. NAFC http://www.nafc.org/nocturia/
  • Consider afternoon naps. NAFC http://www.nafc.org/nocturia/  Also see the National Healthy Sleep Awareness Projects for tips on naps: http://www.sleepeducation.org/healthysleep
  • Cessation of smoking can also help as it is associated with nocturnal voids. (Asplund, 2005).
  • Occupational therapists can be trained in Cognitive Behavioral Therapy for Insomnia (CBT-I) (Green & Hicks, 2005). Advanced training is required.
  • Brief behavioral treatment of insomnia (BBTI)-focus on sleep education, sleep restriction, regular sleep routine, only going to sleep when sleepy, getting out of bed when not asleep (Tyagi et al., 2014). Advanced training is required.
  • Progressive pelvic floor muscle exercises. Occupational therapists skilled in this area can also provide this treatment (Hunjan & Twiss, 2013).  Refer to skilled PT, if indicated, for pelvic floor and other safe conditioning exercises.  See the American Physical Therapy Association website: http://www.apta.org/search.aspx?q=pelvic%20floor%20exercises
  • Consider safety, equipment needs, family members, referrals. See below.

Safety and the Environment

Ensure safe environment as people with nocturia are at high risk for falls.  See the American Occupational Therapy Association’s detailed booklet of information and articles on home safety, “Focus on Falls Prevention and Home Modification Booklet.”  http://www.aota.org/

See tips from the Health in Aging home safety tips: http://www.healthinaging.org/files/documents/tipsheets/home_safety.pdf

Examples of DME Consideration for Safety in ADL

  • Durable medical equipment such as bedside commode, raised toilet seat or rails.
  • Someone who primarily uses a wheelchair during the day may need elevating legrests on their wheelchair if edema is present.
  • Recommend use of urinal by the bedside. There are spill-proof urinals available, though some do not take much volume.  There are dozens of products out there, so make sure you check them out.
  • Possible use of incontinence products, bed pads, and mattress covers if there is leakage.
  • People who use wheelchairs may need a pad on their seat, but caution should be taken if the wheelchair cushion is made for skin protection. When ordering wheelchair cushions, find out if there are covers to protect the cushion without compromising the effectiveness of the cushion to maintain skin integrity.
  • Consult with a PT for possible ambulation aides for use at night.

Remember the Caregivers and Others in the Household

Keep in mind that caregivers and other family members may also be waking up frequently to help someone with nocturia or because they are awakened.

Referrals

Most likely, the reason that a client is referred to OT is not primarily for nocturia.  Many people whom OTs treat regularly such as older adults and those with diabetes, hypertension or cardiac conditions are at risk for the condition (National Association for Continence).  If a client has this complaint, the client should be referred to their physician as a medical condition may be causing it.  Nocturia is such a complex problem, so multiple team members including various medical specialists (urology, sleep, uro-gynecology, nephrology, psychiatry, cardiology, pulmonology, etc.).  Physical therapists, dieticians, psychologists and occupational therapists could also be involved.  Because OTs may be involved in helping people with personal self care activities, they may be the first to hear about it.

See this clip for more information on the relationship between nocturia and sleep:

Nocturia and Sleep, ICS 2014 Donald Bliwise, Nov, 2014 at International Continence Society.

https://www.youtube.com/watch?v=Pyms4w7K16g

References

American Occupational Therapy Association.  (2014).  Occupational therapy practice framework: Domain and process (3rd ed.).  American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48.  http://dx.doi.org/10.5014/ajot.2014.682006

Asplund, R.  (2005).  Management of nocturia in the elderly.  Aging Health, 1(2), 273-283.

Asplund, R., & Aberg, H.  (1992).  Health of the elderly with regard to sleep and nocturnal micturition.  Scandinavian Journal Primary Health Care, 10, 98-104.

Asplund, R., Henriksson, S., Johansson, S., & Isacsson, G.  (2004).  Nocturia and depression.  BJU International, 93(9):1253-6.  doi:10.1111/j.1464-410X.2004.04835.x

Bliwise, D. L., Holm-Larsen, T., Goble, S., & Nørgaard, J. P.  (2015).  Short time to first void is associated with lower whole-night sleep quality in nocturia patients.  Journal of Clinical Sleep Medicine, 11(1), 53-55.

Burgio, K. L., Goode, P. S., Johnson, T. M., Hammontree, L., Ouslander, J. G., Markland, A. D.,…Redden, D. T.  (2010).  Behavioral versus drug treatment for overactive bladder in men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial.  Journal of the American Geriatric Society, 59, 2209-2216. doi: 10.1111/j.1532-5415.2011.03724.x

Cho, S. Y., Lee, S. L., Kim, I. S., Koo, D. H., Kim, H. J., & Oh, S. J.  (2012).  Short-term effects of systematized behavioral modification program for nocturia: A prospective study.  Neurourology and Urodynamics, 31, 64-68.  doi: 10.1002/nau.21186

Green, A., & Hicks, J, Weekes, r., & Wilson, S.  (2005).  A cognitive-behavioural group intervention for people with chronic insomnia: An initial evaluation.  British Journal of Occupational Therapy, 68(11), 518-522.

Hashim, H., &  Abrahms, P.  (2008).  How should patients with an overactive bladder manipulate their fluid intake?  BJU International, 102, 62-66.  doi: 10.1111/j.1464-410X.2008.07463.x

Hunjan, R., & Twiss, K. L.  (2013).  Urgent interventions.  OT Practice, 18(21), 8-12.

Kassai, K., & Perelli, K.  (2012).  The bathroom key: Put an end to incontinence.  New York: demosHealth.

Morris, J. L., Sereika, S. M., Houze, M., & Chasens, E. R.  (2016).  Effect of nocturia on next-day sedentary activity in adults with type 2 diabetes.  Applied Nursing Research, 21, 44-46.  Retrieved from http://dx.doi.org/10.1016/j.apnr.2016.04.006

National Association for Continence.  Retrieved from http://www.nafc.org/home

Obayashi, K., Saeki, K., & Kurumatani, N.  (2015).  Quantitative association between nocturnal voiding frequency and objective sleep quality in the general elderly population: the HEIJO-KYO cohort.  Sleep Medicine, 16(5), 577-582.  http://dx.doi.org/10.1016/j.sleep.2015.01.021

Ohayon, M. M., Krystal, A., Roehrs, T. A., Roth, T., Vitiell, M. V.  (2010).  Using difficulty resuming sleep to define nocturnal awakening.  Sleep Medicine, 11, 236-241.

Soda, T., Masui, K., Okuno, H., Terai, A., Ogawa, O., & Yoshimura, K.  (2010).  Efficacy of nondrug lifestyle measures for the treatment of nocturia.  Journal of Urology, 184, 1000-1004. doi: http://dx.doi.org/10.1016/i.juro.2010.05.038

Tikkinen, K. A., Johnson, T. M., Tammela, T. L., Sintonen, H., Haukka, J., Huhtala, H., & Auvinen, A.  (2010).  Nocturia frequency, bother, and quality of life: How often is too often?  A population-based study in Finland.  European Urology, 57(3), 488-96. doi: 10.1016/j.eururo.2009.03.080.

Tyagi, S., Resnick, N. M., Perera, S., Monk, T. H., Hall, M. H., & Buysse, D. J.  (2014).  Behavioral treatment of chronic insomnia in older adults: Does nocturia matter?  Sleep, 37(4), 681-687.  http://dx.doi.org/10.5665/sleep.3568

Zeitzer, J. M., Bliwise, D. L., Hernandez, B., Friedman, L., & Yesavage, J. A. (2013).  Nocturia compounds nocturnal wakefulness in older individuals with insomnia.  Journal of Clinical Sleep Medicine, 9(3), 259-262.  http://dx.doi.org/10.5664/jcsm.2492

Other Resources

American Academy of Sleep Medicine: http://www.aasmnet.org/

American Occupational Therapy Association: http://www.aota.org/

Bladder and Bowel Foundation: https://www.bladderandbowelfoundation.org/bladder/bladder-conditions-and-symptoms/nocturnal-enuresis/

International Continence Society: http://www.ics.org/

National Healthy Sleep Awareness Project: http://www.sleepeducation.org/healthysleep

National Sleep Foundation: https://sleepfoundation.org/

Urology Care Foundation: http://www.urologyhealth.org/urologic-conditions/bed-wetting-(enuresis)

Content on this page contributed by Jean Koketsu