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Management of Urinary Incontinence in Older Adults in Rehabilitation Care Settings

  • Camille P. VaughanEmail author
  • Colleen M. Fitzgerald
  • Alayne D. Markland
Geriatric Rehabilitation (P Kortebein, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Geriatric Rehabilitation

Abstract

Purpose of Review

This review focuses on updates in the management of urinary incontinence occurring in older adult populations living with conditions frequently managed by physical medicine and rehabilitation specialists.

Recent Findings

Urinary incontinence is common among older adults who live with neurologic diseases, such as stroke, Parkinson’s disease, multiple sclerosis, and traumatic brain injury, and may be cared for in outpatient and acute rehabilitation facilities. While the evidence is growing regarding treatment strategies specific to patients with neurogenic bladder, behavioral treatment approaches may be a viable first option depending on cognitive status and mobility. Drug therapy choices should consider mechanism of action and formulation to minimize the potential for adverse effects. Minimally invasive strategies provided by continence specialists are available for refractory symptoms.

Summary

Evidence suggests a multidisciplinary approach incorporating multicomponent treatment strategies can improve common urinary symptoms among older adults in both outpatient and acute inpatient rehabilitation settings of care.

Keywords

Urinary incontinence Acute inpatient rehabilitation Neurogenic bladder Behavioral therapy Drug therapy 

Notes

Compliance with Ethical Standards

Conflict of Interest

Camille Vaughan reports that her spouse is a full-time employee at Kimberly-Clark Corp outside the submitted work, and grant funding from the US Department of Veterans Affairs, National Institutes of Health, and the Agency for Healthcare Research & Quality. Colleen Fitzgerald reports personal fees from an UptoDate Editor, non-financial support from Board Membership with the International Pelvic Pain Society, personal fees from employment with the Loyola University Chicago Medical Center, personal fees from Expert Testimony, grants from NICHD K23 (finished in 2016), travel and registration expenses as a PAINweek lecturer, and personal fees as an editor outside the submitted work. In addition, Dr. Fitzgerald has a US Patent Application No. 14/213,880 issued. Alayne Markland declares no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    • Mallinson T, Fitzgerald CM, Neville CE, Almagor O, Manheim L, Deutsch A, et al. Impact of urinary incontinence on medical rehabilitation inpatients. 2017;36(1):176–83.  https://doi.org/10.1002/nau.22908. Summary of studies demonstrating prevalence of incontinence and association with clinical outcomes in common rehabiliation patients.
  2. 2.
    Gosch M, Talasz H, Nicholas JA, Kammerlander C, Lechleitner M. Urinary incontinence and poor functional status in fragility fracture patients: an underrecognized and underappreciated association. J Arch Ortho Trauma Surg. 2015;135(1):59–67.  https://doi.org/10.1007/s00402-014-2113-6.Google Scholar
  3. 3.
    Vaughan CP, Markland AD, Smith PP, Burgio KL, Kuchel GA. Report and research agenda of the American Geriatrics Society and National Institute on Aging bedside-to-bench conference on urinary incontinence in older adults: a translational research agenda for a complex geriatric syndrome. J Am Geriatr Soc. 2017;66(4):773–82.  https://doi.org/10.1111/jgs.15157.Google Scholar
  4. 4.
    Milsom I, Altman D, Cartwright R, Lapitan MCM, Nelson R, Sjostrom S, et al. Epidemiology of urinary incontinence and other lower urinary tract symptoms, pelvic organ prolapse, and anal incontinence. Incontinence 6th edition. Bristol, UK: International Continence Society; 2017.Google Scholar
  5. 5.
    Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–78.Google Scholar
  6. 6.
    Fowler CJ, Dalton C, Panicker JN. Review of neurologic diseases for the urologist. Urol Clin N Am. 2010;37(4):517–26.  https://doi.org/10.1016/j.ucl.2010.07.004.Google Scholar
  7. 7.
    Hall SA, Curto TM, Onyenwenyi A, Lemack GE, Tennstedt SL, Link CL, et al. Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) survey. 2012;31(7):1149–55.  https://doi.org/10.1002/nau.22232.
  8. 8.
    Ruffion A, Castro-Diaz D, Patel H, Khalaf K, Onyenwenyi A, Globe D, et al. Systematic review of the epidemiology of urinary incontinence and detrusor overactivity among patients with neurogenic overactive bladder. Neuroepidemiology. 2013;41(3–4):146–55.  https://doi.org/10.1159/000353274.Google Scholar
  9. 9.
    Kushner DS, Johnson-Greene D. Association of urinary incontinence with cognition, transfers and discharge destination in acute stroke inpatient rehabilitation. J Stroke Cerebrovasc Dis. 2018;27(10):2677–82.  https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.05.028.Google Scholar
  10. 10.
    Kovindha A, Wattanapan P, Dejpratham P, Permisirivanich W, Kuptniratsaikul V. Prevalence of incontinence in patients after stroke during rehabilitation: a multi-centre study. J Rehabili Med. 2009;41(6):489–91.Google Scholar
  11. 11.
    Gallagher DA, Lees AJ, Schrag A. What are the most important nonmotor symptoms in patients with Parkinson’s disease and are we missing them? Mov Disord. 2010;25(15):2493–500.  https://doi.org/10.1002/mds.23394.Google Scholar
  12. 12.
    McDonald C, Winge K, Burn DJ. Lower urinary tract symptoms in Parkinson’s disease: prevalence, aetiology and management. Parkinson Relat Disord. 2017;35:8–16.  https://doi.org/10.1016/j.parkreldis.2016.10.024.Google Scholar
  13. 13.
    Balash Y, Peretz C, Leibovich G, Herman T, Hausdorff JM, Giladi N. Falls in outpatients with Parkinson’s disease: frequency, impact and identifying factors. J Neurol. 2005;252:1310–5.Google Scholar
  14. 14.
    Vaughan CP, Brown CJ, Goode PS, Burgio KL, Allman RM, Johnson TM. The association of nocturia with incident falls in an elderly community-dwelling cohort. Int J Clin Pract. 2010;64(5):577–83.  https://doi.org/10.1111/j.1742-1241.2009.02326.x.Google Scholar
  15. 15.
    Sakushima K, Yamazaki S, Fukuma S, Hayashino Y, Yabe I, Fukuhara S, et al. Influence of urinary urgency and other urinary disturbances on falls in Parkinson’s disease. J Neurol Sci. 2016;360:153–7.  https://doi.org/10.1016/j.jns.2015.11.055.Google Scholar
  16. 16.
    Tanji H, Anderson KE, Gruber-Baldini AL, Fishman PS, Reich SG, Weiner WJ, et al. Mutuality of the marital relationship in Parkinson’s disease. Mov Disord. 2008;23(13):1843–9.Google Scholar
  17. 17.
    Luppa M, Luck T, Weyerer S, König H-H, Brähler E, Riedel-Heller SG. Prediction of institutionalization in the elderly. A systematic review. Age Ageing. 2010;39(1):31–8.  https://doi.org/10.1093/ageing/afp202.Google Scholar
  18. 18.
    Aarsland D, Larsen JP, Tandberg E, Laake K. Predictors of nursing home placement in Parkinson’s disease: a population-based, prospective study. J Am Geriatr Soc. 2000;48(8):938–42.Google Scholar
  19. 19.
    Fink H, Kuskowski M, Taylor B, Schousboe J, Orwoll E, Ensrud K, et al. Association of Parkinson’s disease with accelerated bone loss, fractures and mortality in older men: the Osteoporotic Fractures in Men (MrOS) study. Osteoporos Int. 2008;19(9):1277–82.  https://doi.org/10.1007/s00198-008-0584-4.Google Scholar
  20. 20.
    Serra MC, Landry A, Juncos JL, Markland AD, Burgio KL, Goode PS, et al. Increased odds of bladder and bowel symptoms in early Parkinson’s disease. Neurourol Urodyn. 2018;37(4):1344–8.  https://doi.org/10.1002/nau.23443.Google Scholar
  21. 21.
    Zecca C, Riccitelli GC, Disanto G, Singh A, Digesu GA, Panicari L, et al. Urinary incontinence in multiple sclerosis: prevalence, severity and impact on patients’ quality of life. 2016;23(7):1228–34.  https://doi.org/10.1111/ene.13010.
  22. 22.
    Massot C, Khenioui H, Agnani O, Guyot M-A, Hautecoeur P, Donze C. Stress urinary incontinence in women with multiple sclerosis. Int Neurourol J. 2016;20(3):224–31.  https://doi.org/10.5213/inj.1630490.245.Google Scholar
  23. 23.
    Khalaf KM, Coyne KS, Globe DR, Armstrong EP, Malone DC, Burks J. Lower urinary tract symptom prevalence and management among patients with multiple sclerosis. Int J MS Care. 2015;17(1):14–25.Google Scholar
  24. 24.
    Keller JJ, Liu S-P, Lin H-C. Traumatic brain injury increases the risk of female urinary incontinence. 2013;32(4):354–8.  https://doi.org/10.1002/nau.22309.
  25. 25.
    Markland AD, Vaughan CP, Okosun IS, Goode PS, Burgio KL, Johnson TM. Cluster analysis of multiple chronic conditions associated with urinary incontinence among women in the USA. BJU Int. 2018;epub ahead of print. doi:;122:1041–8.  https://doi.org/10.1111/bju.14246.Google Scholar
  26. 26.
    Davis NJ, Vaughan CP, Johnson TM II, Goode PS, Burgio KL, Redden DT, et al. Caffeine intake and its association with urinary incontinence in United States men: results from National Health and Nutrition Examination Surveys. J Urol. 2013;189(6):2170–4.  https://doi.org/10.1016/j.juro.2012.12.061.Google Scholar
  27. 27.
    Jura YH, Townsend MK, Curhan GC, Resnick NM, Grodstein F. Caffeine intake, and the risk of stress, urgency and mixed urinary incontinence. J Urol. 2011;185(5):1775–80.  https://doi.org/10.1016/j.juro.2011.01.003.Google Scholar
  28. 28.
    Townsend MK, Jura YH, Curhan GC, Resnick NM, Grodstein F. Fluid intake and risk of stress, urgency, and mixed urinary incontinence. Am J Obstetr Gynecol. 2011;205(1):73.e1–6.  https://doi.org/10.1016/j.ajog.2011.02.054.Google Scholar
  29. 29.
    Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infect Dis Clin N Am. 2003;17(2):367–94.Google Scholar
  30. 30.
    Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643–54.  https://doi.org/10.1086/427507.Google Scholar
  31. 31.
    Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ et al. Diagnosis, evaluation, and follow-up of asymptomatic microhematuria in adults. American Urological Association. 2016. https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-for-currency-2016). Accessed November 30 2018.
  32. 32.
    Cifu DX, Stewart DG. Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions. Arch Phys Med Rehabil. 1999;80(5 Suppl 1):S35–9.Google Scholar
  33. 33.
    Wikander B, Ekelund P, Milsom I. An evaluation of multidisciplinary intervention governed by functional independence measure (FIMSM) in incontinent stroke patients. Scand J Rehabil Med. 1998;30(1):15–21.Google Scholar
  34. 34.
    Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, et al. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev. 2005;3:CD004462.  https://doi.org/10.1002/14651858.CD004462.pub2.Google Scholar
  35. 35.
    Booth J, Kumlien S, Zang Y, Gustafsson B, Tolson D. Rehabilitation nurses practices in relation to urinary incontinence following stroke: a cross-cultural comparison. J Clin Nurs. 2009;18(7):1049–58.  https://doi.org/10.1111/j.1365-2702.2008.02688.x.Google Scholar
  36. 36.
    Thomas LH, Watkins CL, Sutton CJ, Forshaw D, Leathley MJ, French B, et al. Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial. Trials. 2014;15:509.  https://doi.org/10.1186/1745-6215-15-509.Google Scholar
  37. 37.
    Thomas LH, French B, Sutton CJ, Forshaw D, Leathley MJ, Burton CR et al. Programme Grants for applied research. Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care. Southampton (UK): NIHR journals library, Southampton SO16 7NS, UK.; 2015.Google Scholar
  38. 38.
    Vaughan CP, Juncos JL, Burgio KL, Goode PS, Wolf RA, Johnson TM 2nd. Behavioral therapy to treat urinary incontinence in Parkinson disease. Neurology. 2011;76(19):1631–4.  https://doi.org/10.1212/WNL.0b013e318219fab3.Google Scholar
  39. 39.
    Vaughan CP, Burgio KL, Goode PS, Juncos JL, McGwin G Jr, Johnson TM 2nd. Pelvic floor muscle exercise-based behavioral therapy improves urinary symptoms in Parkinson disease (abstract). Mov Disord. 2017;32(9):e18.Google Scholar
  40. 40.
    Tornic J, Panicker JN. The management of lower urinary tract dysfunction in multiple sclerosis. Curr Neurol Neurosci Rep. 2018;18(8):54.  https://doi.org/10.1007/s11910-018-0857-z.Google Scholar
  41. 41.
    Tornic J, Sartori AM, Gajewski JB, Cox A, Schneider MP, Youssef NA, et al. Catheterization for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: a systematic review. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS). Neurourol Urodyn. 2018;37(8):2315–22.  https://doi.org/10.1002/nau.23733.Google Scholar
  42. 42.
    McClurg D, Ashe RG, Lowe-Strong AS. Neuromuscular electrical stimulation and the treatment of lower urinary tract dysfunction in multiple sclerosis--a double blind, placebo controlled, randomised clinical trial. Neurourol Urodyn. 2008;27(3):231–7.  https://doi.org/10.1002/nau.20486.Google Scholar
  43. 43.
    Lucio AC, Campos RM, Perissinotto MC, Miyaoka R, Damasceno BP, D'Ancona CA. Pelvic floor muscle training in the treatment of lower urinary tract dysfunction in women with multiple sclerosis. Neurourol Urodyn. 2010;29(8):1410–3.  https://doi.org/10.1002/nau.20941.Google Scholar
  44. 44.
    Ouslander JG, Schnelle JF, Uman G, Fingold S, Nigam JG, Tuico E, et al. Predictors of successful prompted voiding among incontinent nursing home residents. JAMA. 1995;273(17):1366–70.  https://doi.org/10.1001/jama.1995.03520410060027.Google Scholar
  45. 45.
    Schnelle JF, Leung FW, Rao SS, Beuscher L, Keeler E, Clift JW, et al. A controlled trial of an intervention to improve urinary and fecal incontinence and constipation. J Am Geriatr Soc. 2010;58(8):1504–11.  https://doi.org/10.1111/j.1532-5415.2010.02978.x.Google Scholar
  46. 46.
    Drennan VM, Greenwood N, Cole L, Fader M, Grant R, Rait G, et al. Conservative interventions for incontinence in people with dementia or cognitive impairment, living at home: a systematic review. BMC Geriatr. 2012;12:77.  https://doi.org/10.1186/1471-2318-12-77.Google Scholar
  47. 47.
    Keller JJ, Liu SP, Lin HC. Traumatic brain injury increases the risk of female urinary incontinence. Neurourol Urodyn. 2013;32(4):354–8.  https://doi.org/10.1002/nau.22309.Google Scholar
  48. 48.
    Moody BJ, Liberman C, Zvara P, Smith PP, Freeman K, Zvarova K. Acute lower urinary tract dysfunction (LUTD) following traumatic brain injury (TBI) in rats. Neurourol Urodyn. 2014;33(7):1159–64.  https://doi.org/10.1002/nau.22470.Google Scholar
  49. 49.
    Halleberg Nyman M, Forsman H, Ostaszkiewicz J, Hommel A, Eldh AC. Urinary incontinence and its management in patients aged 65 and older in orthopaedic care - what nursing and rehabilitation staff know and do. J Clin Nurs. 2017;26(21–22):3345–53.  https://doi.org/10.1111/jocn.13686.Google Scholar
  50. 50.
    Halleberg Nyman M, Forsman H, Wallin L, Ostaszkiewicz J, Hommel A, Eldh AC. Promoting evidence-based urinary incontinence management in acute nursing and rehabilitation care-a process evaluation of an implementation intervention in the orthopaedic context. J Eval Clin Pract. 2018;25:282–9.  https://doi.org/10.1111/jep.12879.Google Scholar
  51. 51.
    AGS Beers Criteria Update Expert P. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46.  https://doi.org/10.1111/jgs.13702.Google Scholar
  52. 52.
    Zesiewicz TA, Evatt M, Vaughan CP, Jahan I, Singer C, Ordorica R, et al. Randomized, controlled pilot trial of solifenacin succinate for overactive bladder in Parkinson’s disease. Parkin Relat Disord. 2015;21(5):514–20.  https://doi.org/10.1016/j.parkreldis.2015.02.025.Google Scholar
  53. 53.
    Amarenco G, Sutory M, Zachoval R, Agarwal M, Del Popolo G, Tretter R, et al. Solifenacin is effective and well tolerated in patients with neurogenic detrusor overactivity: results from the double-blind, randomized, active- and placebo-controlled SONIC urodynamic study. Neurourol Urodyn. 2017;36(2):414–21.  https://doi.org/10.1002/nau.22945.Google Scholar
  54. 54.
    Yamanouchi. Vesicare (solifenacin succinate) tablet prescribing information. Paramus, NJ2004.Google Scholar
  55. 55.
    Chapple CR, Nazir J, Hakimi Z, Bowditch S, Fatoye F, Guelfucci F, et al. Persistence and adherence with mirabegron versus antimuscarinic agents in patients with overactive bladder: a retrospective observational study in UK clinical practice. Eur Urol. 2017;72(3):389–99.  https://doi.org/10.1016/j.eururo.2017.01.037.Google Scholar
  56. 56.
    Kelleher C, Hakimi Z, Zur R, Siddiqui E, Maman K, Aballéa S, et al. Efficacy and tolerability of mirabegron compared with antimuscarinic monotherapy or combination therapies for overactive bladder: a systematic review and network meta-analysis. Eur Urol. 2018;74(3):324–33.  https://doi.org/10.1016/j.eururo.2018.03.020.Google Scholar
  57. 57.
    Burgio KL, Goode PS, Johnson TM, Hammontree L, Ouslander JG, Markland AD, et al. Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial. J Am Geriatr Soc. 2011;59(12):2209–16.  https://doi.org/10.1111/j.1532-5415.2011.03724.x.Google Scholar
  58. 58.
    Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial. JAMA. 2006;296(19):2319–28.Google Scholar
  59. 59.
    Force USPST. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(18):1901–13.  https://doi.org/10.1001/jama.2018.3710.Google Scholar
  60. 60.
    Maund E, Guski LS, Gøtzsche PC. Considering benefits and harms of duloxetine for treatment of stress urinary incontinence: a meta-analysis of clinical study reports. Can Med Assoc J. 2017;189(5):E194–203.Google Scholar
  61. 61.
    Canbaz Kabay S, Kabay S, Mestan E, Cetiner M, Ayas S, Sevim M, et al. Long term sustained therapeutic effects of percutaneous posterior tibial nerve stimulation treatment of neurogenic overactive bladder in multiple sclerosis patients: 12-months results. 2017;36(1):104–10.  https://doi.org/10.1002/nau.22868.
  62. 62.
    Kabay S, Canbaz Kabay S, Cetiner M, Mestan E, Sevim M, Ayas S, et al. The clinical and urodynamic results of percutaneous posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with Parkinson’s disease. Urology. 2016;87:76–81.  https://doi.org/10.1016/j.urology.2015.09.026.Google Scholar
  63. 63.
    Peters KM, Kandagatla P, Killinger KA, Wolfert C, Boura JA. Clinical outcomes of sacral neuromodulation in patients with neurologic conditions. Urology. 2013;81(4):738–44.  https://doi.org/10.1016/j.urology.2012.11.073.Google Scholar
  64. 64.
    • Visco AG, Brubaker L, Richter HE, Nygaard I, MFR P, Menefee SA, et al. Anticholinergic therapy vs. onabotulinumtoxinA for urgency urinary incontinence. N Engl J Med. 2012;367(19):1803–13.  https://doi.org/10.1056/NEJMoa1208872. While not performed in a neurogenic bladder population, this comparative effectiveness trial in 249 women demonstrates the relative benefits and risks of onabotulinumtoxinA compared with anticholinergic drug therapy. The group receiving onabotulinumtoxinA was less likely to have dry mouth and had higher rates of transient urinary retention and urinary tract infections. Reductions in incontinence episodes were similar between the two groups. Google Scholar
  65. 65.
    • Amundsen CL, Richter HE, Menefee SA, et al. Onabotulinumtoxina vs sacral neuromodulation on refractory urgency urinary incontinence in women: a randomized clinical trial. JAMA. 2016;316(13):1366–74.  https://doi.org/10.1001/jama.2016.14617. While not performed in a neurogenic bladder population, this comparative effectiveness study in 364 women with a mean age of 63 years showed the two treatments had clinically similar impact to reduce urgency urinary incontinence. OnabotulinumtoxinA was associted with higher risk of urinary tract infections and transient need for self-catheterization. Neuromodulation device revisions and removals occurred in 3% of participants. Google Scholar
  66. 66.
    Knüpfer SC, Schneider SA, Averhoff MM, Naumann CM, Deuschl G, Jünemann K-P, et al. Preserved micturition after intradetrusor onabotulinumtoxinA injection for treatment of neurogenic bladder dysfunction in Parkinson’s disease. BMC Urol. 2016;16(1):55.  https://doi.org/10.1186/s12894-016-0174-2.Google Scholar
  67. 67.
    Anderson RU, Orenberg EK, Glowe P. OnabotulinumtoxinA office treatment for neurogenic bladder incontinence in Parkinson’s disease. Urology. 2014;83(1):22–7.  https://doi.org/10.1016/j.urology.2013.09.017.Google Scholar
  68. 68.
    Kennelly M, Dmochowski R, Schulte-Baukloh H, Ethans K, Del Popolo G, Moore C, et al. Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: final results of a long-term extension study. Neurourol Urodyn. 2017;36(2):368–75.  https://doi.org/10.1002/nau.22934.Google Scholar

Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  • Camille P. Vaughan
    • 1
    Email author
  • Colleen M. Fitzgerald
    • 2
  • Alayne D. Markland
    • 3
  1. 1.Birmingham/Atlanta VA GRECC, Division of General Medicine & Geriatrics, Department of MedicineEmory UniversityDecaturUSA
  2. 2.Department of Obstetrics and Gynecology, Department of Orthopedics and Rehabilitation, Division Female Pelvic Medicine and Reconstructive SurgeryLoyola University Chicago Stritch School of MedicineMaywoodUSA
  3. 3.Birmingham/Atlanta VA GRECC, Division of Gerontology, Geriatrics & Palliative Care, Department of MedicineUniversity of Alabama at BirminghamBirminghamUSA

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