Oral ddAVP for Nighttime Urinary Incontinence in Characterized Nursing Home Residents: A Pilot Study Theodore M. Johnson, II, MD, MPH, CMD, Myron Miller, MD, Terence Tang, MD, Dennis J. Pillion, PhD, and Joseph G. Ouslander, MD, CM Objectives: To (1) identify abnormalities in arginine vasopressin (AVP, a water-conserving hormone) secre- tion and release in nursing home (NH) residents with nighttime urinary incontinence (UI); and (2) perform a pilot test of desmopressin acetate (ddAVP, a synthetic analog of the naturally occurring hormone) replace- ment in these residents. Design: Diagnostic evaluation and open-label treat- ment trial. Setting: Two community nursing homes in a metropol- itan area. Participants: Male and female NH residents 65 years of age and older with nighttime UI. Intervention: Characterizations of AVP status fol- lowed by a 7-day open-label trial of oral ddAVP (either 0.1 mg or 0.2 mg). Measurements: Water deprivation test results, AVP levels, voided volumes, number of voids, incontinent episodes, number of nighttime checks found wet (out of 6 total checks per night). Results: All participants had measurable AVP levels of 2.0 pg/mL or higher. Six of 10 individuals had an abnor- mal water deprivation test. Two of 4 participants on 0.2 mg of ddAVP and 2 of 6 participants on 0.1 mg had a 200 mL or more mean reduction in nighttime urine volume. Both ddAVP dosages yielded a mean reduction of 0.7 fewer nighttime wet checks found wet. One participant in each group developed hyponatremia (1 of 6 on 0.1 mg and 1 of 4 on 0.2 mg). Hyponatremia resolved with discontinuation of the drug. Conclusion: Both 0.1 mg and 0.2 mg of ddAVP given to carefully screened NH residents for 7 days produced a modest average reduction in nighttime urine volume and number of nighttime incontinent episodes that is likely of little clinical importance. The role of ddAVP in this population requires further research. (J Am Med Dir Assoc 2006; 7: 6 –11) Keywords: Urinary incontinence; nursing home; des- mopressin; nighttime UI Urinary incontinence (UI) is a costly and highly prevalent condition among nursing home (NH) residents. 1– 4 Behavioral interventions are effective for the treatment of daytime urinary incontinence in a substantial number of residents. 5–7 Residents with daytime UI often have nighttime UI as well. NH residents needing to void at night often attempt unassisted nighttime trips to the bathroom; they either forget to request assistance or urinary urgency renders them unable to wait for assistance resulting in risk of falls and injury. Additionally, nighttime UI may contribute to problems with skin integrity and does disrupt sleep. No drugs or behavioral interventions have been shown to be effective in the treatment of nighttime incontinence. A prompted voiding protocol adapted for nighttime use resulted in little improvement to nighttime UI and may be disruptive to sleep. 8 As older adults age, there is a dysregulation of the normal diurnal rhythm of arginine vasopressin (AVP) secretion and urine production in which blood AVP levels are higher at night with corresponding lower rate of urine production at night. The consequence of the dysregulation is a decrease in AVP secretion at night and increased nighttime urine vol- The Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Cen- ter, Atlanta, GA (T.M.J., J.G.O.); The Emory Center for Health in Aging, At- lanta, GA (T.M.J., J.G.O.); Division of Geriatric Medicine and Gerontology, and Wesley Woods Center of Emory University, Emory University School of Medi- cine, Atlanta, GA (T.M.J., J.G.O.); Division of Geriatric Medicine, Sinai Hospital of Baltimore, Johns Hopkins University School of Medicine, Baltimore, MD (M.M.); Department of Geriatrics, Alexandra Hospital, Singapore (T.T.); De- partment of Pharmacology and Toxicology, University of Alabama at Birming- ham School of Medicine, Birmingham, AL (D.J.P.). Support for this study was through a National Institutes of Health MERIT award (J.G.O.) from the National Institute on Aging (5-R37-AG08678), and a VISN 7 VA Career Development Award (T.M.J.). The Atlanta VA Rehabilitation Research and Development Center provided additional support. Address correspondence to Theodore M. Johnson, II, MD, MPH, CMD, Bir- mingham/Atlanta GRECC, 508/11B, Atlanta VAMC, 1670 Clairmont Road, De- catur, GA 30033. E-mail: Ted.Johnson@med.va.gov Copyright ©2006 American Medical Directors Association DOI: 10.1016/j.jamda.2005.04.010 6 Johnson et al. JAMDA – January 2006