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Management of Urinary Incontinence in Residential Care

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Management of Urinary Incontinence in Residential Care CLINICAL Management of urinary incontinence in residential care David S Lim Background he International Continence Society Current epidemiology data and total cost defines urinary incontinence as of incontinence in RACFs are likely to be Urinary incontinence is prevalent T ‘the complaint of any involuntary under-estimated because incontinence is in residential care and rates are leakage of urine’, which stands alongside under-reported, under-screened and under- expected to increase with the ageing an older definition of ‘involuntary loss of treated. Exact numbers are scant because population in Australia. It contributes urine that is a social or hygienic problem’.1 there is a lack of research, particularly to poor quality of life (QoL), functional There are three subtypes of urinary relating to faecal incontinence alone. impairments in activities of daily living, and deterioration of mental and sexual incontinence – urge, stress and mixed Urinary incontinence incidence rates are health. Management depends on the – and other less common subtypes of estimated to be 27% after being in RACFs 5 type of incontinence, its aetiology, the overflow and functional incontinence for two months. severity of symptoms, the effects on (Table 1).2 Urinary incontinence is not a The prevalence of incontinence in QoL, and patient factors. Treatment physiological part of ageing, although RACFs is significantly higher than in the options include active treatment and age-related changes in the urinary tract general population because of the aged passive containment. However, not all and other factors related to ageing demographic with deteriorating cognition active treatment options are feasible in leave older adults more susceptible.3 and function, impaired mobility and residential care. There is little evidence Being incontinent directly and indirectly accumulated comorbidities, all of which to advise on standard best practice. increases the risk of falls and related are proven risk factors for incontinence.7 fractures, thus increasing morbidity In 2009, three out of four people living Objective and mortality.3 It is associated with in cared accommodation in Australia The aims of this article are to poorer quality of life (QoL), functional had severe incontinence and needed review treatment options for urinary impairments in activities of daily living, assistance with managing their bladder or 5 incontinence in residential care, deterioration of mental and sexual health, bowel control. feasibility of service delivery and and sleep disruptions, and has an impact The cost of incontinence in Australia challenges associated with this. on residential outcomes.3,4 According was estimated to be $1.6 billion in the to 87% of aged care assessment team 2008–09 financial year, with residential care Discussion respondents, incontinence is a significant expenditure contributing $1.3 billion.5 This deciding factor for transition to living in formed about 30% of the total residential A greater understanding of the issues residential care.5 aged care government subsidy. In that surrounding the management of urinary same period, the federal government incontinence in residential care is Burden of disease provided $31.6 million for the Continence required to deliver satisfactory patient- Residential aged care facilities (RACFs) Aids Assistance Scheme (CAAS), which centred care on a consistent basis. provide ‘respite or permanent care for frail represented an average increase of 34.6% or disabled people who can no longer live per year from 2006–07.5 A national burden in their own homes, combining residential, of disease analysis, which takes into personal and nursing care for 9% of account prevalence estimates, severity Australians’.6 The estimated occupancy rate data and disability weights, concluded that is 92% and is forecasted to remain high residents in care lost 39,200 healthy life given the ageing Australian population.6 years as a result of incontinence.5 498 AFP VOL.45, NO.7, JULY 2016 © The Royal Australian College of General Practitioners 2016 URINARY INCONTINENCE IN RESIDENTIAL CARE CLINICAL Table 1. Types of urinary incontinence1,2,8,23,24 Type Symptoms Pathophysiology Common aetiologies Urge • Involuntary leakage accompanied by strong Detrusor overactivity or • Urinary tract infection desire to void ± frequency and nocturia instability • Atrophic vaginitis, stroke • Patient typically loses urine on the way to toilet • Spinal cord injury and certain activites (running water, cold weather, • Parkinson’s disease etc) can trigger urine loss • Volume of urine loss is variable Stress • Involuntary leakage due to increases in intra- Pelvic floor/bladder neck • Childbirth abdominal pressure on effort or exertion (eg on weakening or internal • Obesity laughing, sneezing, coughing and lifting) sphincter dysfunction from • Post-prostatectomy • Patient can usually predict which activities will increased urethral mobility cause leakage • In severe cases, it occurs with minimal activity (eg walking, standing from sitting) and limited awareness of leakage Mixed • Involuntary leakage associated with features of Combination of the above • Combination of the above urgency and stress incontinence Overflow (urinary • Involuntary leakage with loss of fullness sensation Overdistention of the bladder • Anticholinergic agents retention) from an overdistended bladder from impaired detrusor • Benign prostatic hyperplasia • Associated with obstructive symptoms such as contractility or bladder outlet • Pelvic organ prolapse obstruction dribbling, hesitancy and poor stream • Diabetes mellitus • Patient often feels that there is incomplete • Multiple sclerosis bladder emptying • Spinal cord injuries • Tends to occur with post-void residual volumes • Faecal impaction of >300 mL • Prostatomegaly or pelvic mass Table 2. Assessment of urinary incontinence1 Management of urinary incontinence Stages of assessment Summary of key points Management depends on the type of History • Genitourinary system incontinence, its aetiology, the severity • Sexual function of symptoms, the effects on QoL and • Other relevant medical history patient factors (eg cognition, functional • Medication history status, medical history). As with other • Obstetric and menstrual history geriatric syndromes, the cause of urinary • Social history • Functional status incontinence is often multifactorial and • Impact of incontinence on quality of life requires a comprehensive approach. A valuable online resource for general Physical examination • General status practitioners (GPs) that provides clinical • Abdominal examination guidelines for the assessment and • Pelvic examination management of urinary incontinence • Relevant neurological examination (Medical care of older persons in Initial tests • Urinalysis residential aged care facilities [the • Bladder diary Silver book]) can be found on The Royal • Renal function Australian College of General Practitioners • Bladder scan estimating post-void residual urine (RACGP) website.8 A summarised • Cough stress test assessment of urinary incontinence is Follow-up tests • Imaging of pelvic and urinary tract with plain films, ultrasound, shown in Table 2. computed tomography or magnetic resonance imaging A few practical points are worth • Endoscopy reiterating – managing fluid and caffeine • Urodynamic testing intake, treating constipation (given the © The Royal Australian College of General Practitioners 2016 AFP VOL.45, NO.7, JULY 2016 499 CLINICAL URINARY INCONTINENCE IN RESIDENTIAL CARE complex interplay between bladder and environment and also to vulnerable evaluated to be well received by bowel function) and minimising certain residents having to adapt to frequent residential care staff.12 medications that can induce incontinence personnel changes. In the past decade, The various treatment options for (eg diuretics, calcium channel blockers, the number of full-time care staff in RACFs incontinence (Table 3, Box 1) may not alpha-adrenoceptor antagonists, has increased by 25%, but registered apply to all residents in the residential antipsychotics, benzodiazepines, nurse employment has decreased by an care setting. Very few studies have antidepressants and hormone alarming 14%.13 looked at the efficacy of active treatment replacement therapy).9 As part of a government initiative, options in the residential care setting, Urinary tract infections (UTIs) may lead specialised assessment tools, which but it seems that toileting assistance to or worsen existing urinary incontinence, are readily available online, have been programs have the most promise in and thus should be treated appropriately developed; these consist of a continence reducing incontinence.14 However, this with antimicrobials.10 The challenge is screening form, management flow chart, can be a labour-intensive approach – a often with diagnosis rather than treatment, bladder and bowel charts, assessment compliance rate of 61% was reported in given the low sensitivity and specificity and care plan, and continence review one trial15 with rates likely to be poorer rates of current diagnostic criteria for form.12 These tools are evidence-based, outside the trial period. Implementing a nursing home residents.1 Asymptomatic comply with professional and accreditation toileting program and maintaining accurate bacteriuria (ASB) is a common occurrence standards, and have recently been voiding records remain the biggest in RACFs and antimicrobial therapy does not result in improved outcomes.11 On the contrary, there
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