Urinary incontinence is a common condition among elderly patients. Patients with incontinence typically have a lower quality of life, with increased rates of depression and mental and sexual impairment.With the rise in aging adults requiring residential care in United States, this condition cannot be ignored.
In this article we aim to describe how to manage urinary incontinence in residential care. We begin by defining urinary incontinence and its causes and symptoms. We then provide management options, dependent on the type and severity of the condition. There is no consensus on the best management practice, as it is likely specific to each patient.
What is Urinary Incontinence?
In the past, urinary incontinence was defined as an involuntary loss of urine that was a social or hygienic problem. Currently, the International Continence Society has a broader definition of any involuntary leakage of urine. They further categorize this condition into urge, stress and mixed sub-types, with overflow and function sub-types being less prevalent. Incontinence in itself is not a normal part of aging, but getting older does change the structure of the urinary tract along with other physical changes that make the elderly more prone to developing this condition.
Urinary incontinence is a major impediment to daily life; either directly or indirectly. For example, patients may awaken often during the night, and with poor quality of sleep they are more susceptible to falls and fractures. This directly increases the risk of injury and can lead to illness and mortality. There are a number of tools that are available to assist, such as bedside commode chairs as well as bedpans and urine bottles. Elderly patients with incontinence typically present with mental and functional decline. They cannot participate as well in day-to-day activities and typically have a lower quality of life. The majority of residential care facility workers say that incontinence is a major factor when considering the move of an elderly patient to a care facility.
Stats & Facts about Incontinence
Currently, about 9% of Americans live in residential aged care facilities (RACFs) or communities, with this number expected to only increase with the aging population. RACFs provide personal, health and nursing care to elderly patients who are too frail or disabled to take care of themselves in their own homes. The economic cost of urinary incontinence in RACFs is unknown and likely underestimated because this condition is typically under diagnosed and not properly managed. One estimation is that incontinence affects around a third of patients in RACFs.
The high prevalence of this condition in RACFs as compared to the general public is because of the high concentration of elderly patients in these facilities. Elderly patients often experience a progressive decline in their ability to function and take care of themselves. It has been estimated that three out of four of these patients in American residential care facilities have incontinence which can be described as severe.
In 2008-2009, the economic burden of incontinence in America was estimated to be $37 billion, with the majority of this expenditure being in residential aged care facilities. This cost was almost one-third of the total governmental subsidy given to RACFs. In addition to the subsidy, the government also paid over $30 million to the Continence Aids Assistance Scheme (CAAS), an increase of over 30% from the previous fiscal year. Disease burden analysis shows that incontinence costs patients in RACFs tens of thousands of healthy life years.
Managing Urinary Incontinence
There is no consensus on the best way to manage incontinence, as it depends on type, cause and severity and how it is affecting each patient in their daily lives. This condition can be caused by a multitude of coexisting factors and can be a challenge to manage.
When assessing a patient, make sure to discuss the amount of daily fluid intake and their caffeine consumption. Also ask about any medications that they may be taking which can cause incontinence as a side effect. Some examples of these medications are diuretics, benzodiazepines and certain antidepressants, anti-psychotics and blood pressure medications.
A history of urinary tract infections (UTIs) may also be a contributing factor to the cause and severity of this condition. If a UTI is present treat with antibiotics. The challenge in RACFs is that this condition often goes undiagnosed by care practitioners, and asymptomatic infections (such as asymptomatic bacteriuria) that do not respond to antimicrobials make diagnosis and treatment more difficult. It is not recommended to treat bacteriuria, because unlike a UTI they do not respond to well to antibiotics and can contribute to the development of antibiotic resistant microbes.
The best treatment option for women is typically pelvic floor muscle training (PFMT). This has been shown to generally improve incontinence symptoms and patient quality of life. However, mental decline in the elderly often restricts the effectiveness of this treatment option, because it is either not practiced or done properly. Most of the literature on this treatment is based on expectant mothers, while only a few studies have looked at geriatric patients. As such, there is little evidence that PFMT is an effective treatment method for women in RACFs.
Reviewing the literature, toileting and using adult diapers are the most common approaches to manage incontinence. Studies looking at full maintenance of continence are lacking, however. This is likely because researchers and caregivers have accepted, whether correct or not, that there is no reversal or cure for this condition. A caregiver should discuss with the ward of the patient what type of incontinence management is most suitable.
Patients prefer medications over the use of diapers because it avoids the embarrassment and dependence on others.
Because the elderly are more sensitive to side-effects and interactions, medications should only be cautiously prescribed. Anticholinergics have side effects such as dry mouth, confusion, and can block the effectiveness of treatments for dementia. The newest medication, Mirabegron, has a more favorable side-effect profile and manages incontinence by increasing the capacity of the bladder. It is as effective as the older anticholinergics but has yet to receive government subsidy. Invasive procedures are unpopular in the RACF setting.
It is important that patients, whenever possible, remain in control of their treatment options. This is difficult in RACFs, because of the nature of the residential setting. The patient’s voice may be overshadowed by other decision makers, such as management who have a budget to adhere to, or by poorly trained caregivers who have limited time and resources to provide to residents on a daily basis.
Treatment in Residential Care
Incontinence is typically under-diagnosed in RACFs because of communication barriers between patients and care practitioners. This may be due to deteriorating mental capacity or simply a language or cultural barrier. For many people, incontinence is associated with a sense of shame or stigma. The associated fear and anxiety often is an impediment for the patients to ask for assistance.
There are over 1,000,000 care practitioners working in American RACFs. Many of these workers come from other countries with different cultural background and minimal training in the diagnosis and management of incontinence. There is also a high turnover rate, leading to many personnel changes with staff working in unfamiliar environments. Furthermore, less skilled registered nurses are working as full-time caregivers, while the number of care practitioners for the elderly is on the rise.
Although there are many treatment options for incontinence, it appears that toileting assistance programs are the most beneficial in residential care. This type of bladder training can be difficult to implement and maintain long-term, however. Patients may not comply with this sort of training and it is demanding to implement for the caregiver. The caregiver must set up the toileting program and keep a log of all bladder and bowel movements. There is a lack of evidence in the literature that shows that bladder training is a successful treatment for incontinence and as such should not be mandatory practice in RACFs.
RACFs are funded by the government through a model that surprisingly rewards higher levels of incontinence. In this funding model, staff may be more focused on securing capital and avoiding penalties than providing the best patient care.
Urinary incontinence remains a major problem in residential care facilities. It is difficult to diagnose and challenging to manage. More research is needed to study the best treatment options for elderly patients to improve their level of care.