An estimated 40% of Parkinson's disease (PD) patients suffer from lower urinary tract symptoms (LUTS) including more than 25% who have urinary incontinence (UI). Current treatment guidelines, that recommend treatment with anticholinergic drugs, are based on expert opinion, because no randomized controlled trials of any therapy for LUTS (including UI) have been completed to date in adults with PD. Anticholinergic medications typically used to treat urinary symptoms can add to the anticholinergic burden of antiparkinsonian therapy, and thus to the cognitive and autonomic burdens of the illness. Meanwhile, behavioral interventions for UI - including pelvic floor muscle exercise (PFME) therapy - have proven efficacy in randomized controlled trials and are free of side effects. Exercise-based behavioral interventions for UI require individuals to learn motor skills (PFME) and implement an adaptive strategy. As a first step in improving evidence-based treatment guidelines, the candidate published an abstract of the only known study demonstrating the feasibility and potential therapeutic benefit of using exercise-based behavioral therapy to treat UI in adults with PD. Randomized controlled trials of behavioral therapy would provide a logical next step to optimize the care of veterans with PD and LUTS. The project goals for this proposal include: 1. Evaluate the efficacy of exercise-based behavioral therapy to treat LUTS among veterans with PD using a randomized controlled trial design. 2. Explore the mechanism utilized by PD participants to learn and implement the exercise-based behavioral strategy as a motor task of procedural learning using implicit memory. 3. Gain knowledge and expertise in aging processes that affect the ability to learn and remember both factual knowledge and procedural skills. 4. Gain understanding of autonomic dysfunction and technical skill in evaluating autonomic function. 5. Gain advanced biostatistical training in the analysis of longitudinal data.


The mentoring team combines faculty with expertise in research methodology, the care of persons with PD, and management of voiding dysfunction. Mentors include: Theodore M. Johnson, II, MD, MPH (Primary, geriatrics), Kathryn L. Burgio, PhD (behavioral psychology), and Jorge L. Juncos, MD (movement disorders). Advisors: Gerald McGwin, PhD (biostatistics) and Felicia Goldstein, PhD (neuropsychology). Career and Research Plan: A randomized controlled trial is proposed to assess the efficacy of pelvic floor muscle exercise-based behavioral therapy to treat LUTS in adults with PD. After stratification by UI severity, PD severity, and gender, a group of 60 subjects (30 in each group) will be randomized to receive behavioral therapy or a behavioral control over 8 weeks. A 6-month follow-up is planned among participants who complete the behavioral therapy intervention. The primary outcome (frequency of UI) will be measured using a seven-day bladder diary. A motor task of procedural learning (Serial Reaction Time Task (SRTT)) will be administered at baseline to all participants. Exploratory analyses will assess performance on the SRTT as a predictor of success in implementing exercise-based behavioral therapy to reduce weekly UI frequency. Career development activities include advanced biostatistical coursework in epidemiologic modeling and longitudinal analyses. Advanced coursework and directed readings in cognitive aging are proposed. The candidate will increase her knowledge of autonomic dysfunction through directed readings, coursework, and practical training. The candidate expects the proposed career and research plan will prepare her to apply for Merit Review funding to establish independence as an investigator and provide needed evidence to support guidelines for the treatment of LUTS in veterans with PD.

Public Health Relevance

Parkinson's disease (PD) affects approximately 1.5% of the United States population over the age of 65. The number of persons with PD is expected to double by 2030 as the size of the elderly population continues to increase. This increase in the prevalence of PD will impact aging veterans as well. Because the veteran population is older than the general population and veterans with PD are 30% more likely than veterans without PD to rely exclusively on VHA for outpatient health care services, VHA will have greater need for expert clinical care. Urinary incontinence (the accidental loss of urine) is one of the most bothersome non- motor symptoms of PD and in later stages of the disease contributes more to poor quality of life than motor disability. Treatments for urinary incontinence that do not involve additional drug therapy would be preferable if effective in this vulnerable population.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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Serra, Monica C; Landry, Alexus; Juncos, Jorge L et al. (2018) Increased odds of bladder and bowel symptoms in early Parkinson's disease. Neurourol Urodyn 37:1344-1348
Fung, Constance H; Vaughan, Camille P; Markland, Alayne D et al. (2017) Nocturia is Associated with Poor Sleep Quality Among Older Women in the Study of Osteoporotic Fractures. J Am Geriatr Soc 65:2502-2509
Kancherla, Vijaya; Elliott Jr, John L; Patel, Birju B et al. (2017) Long-term Metformin Therapy and Monitoring for Vitamin B12 Deficiency Among Older Veterans. J Am Geriatr Soc 65:1061-1066
Vaughan, Camille P; Fung, Constance H; Huang, Alison J et al. (2016) Differences in the Association of Nocturia and Functional Outcomes of Sleep by Age and Gender: A Cross-sectional, Population-based Study. Clin Ther 38:2386-2393.e1
Vaughan, C P; Tangpricha, Vin; Motahar-Ford, N et al. (2016) Vitamin D and incident urinary incontinence in older adults. Eur J Clin Nutr 70:987-9
Vaughan, Camille P; Bliwise, Donald L; Johnson 2nd, Theodore M (2015) Editorial comment. Urology 85:646-7
Zesiewicz, Theresa A; Evatt, Marian; Vaughan, Camille P et al. (2015) Randomized, controlled pilot trial of solifenacin succinate for overactive bladder in Parkinson's disease. Parkinsonism Relat Disord 21:514-20
Wu, Jennifer M; Matthews, Catherine A; Vaughan, Camille P et al. (2015) Urinary, fecal, and dual incontinence in older U.S. Adults. J Am Geriatr Soc 63:947-53
Stevens, Melissa B; Hastings, Susan Nicole; Powers, James et al. (2015) Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel J Am Geriatr Soc 63:1025-9
Vaughan, Camille P; Fowler, Rachel; Goodman, Richard A et al. (2014) Identifying landmark articles for advancing the practice of geriatrics. J Am Geriatr Soc 62:2159-62

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