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

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 is potential for harm Table 3. Overview of treatment options for urinary incontinence1,2,14,16 from side effects of antimicrobials and the Treatment options* development of resistant organisms, thus treatment of ASB (unlike true UTIs) is not Active treatment Lifestyle interventions Weight loss, smoking cessation, fluid reduction, constipation management recommended.11 Physical therapies Pelvic floor muscle training and Considerations in vaginal cones residential care Behavioural therapies Bladder training, prompted or scheduled voiding Incontinence may be under-reported in RACFs because of deteriorating cognition Mechanical devices Continence pessaries, urethral plugs or poor communication abilities. A large Medications Anticholinergic agents, alpha or beta proportion of older people in Australia adrenoceptor agonists, serotonin– were born overseas, thus creating a norepinephrine reuptake inhibitors, botulinum toxin A cultural and language barrier. There For women: intravaginal topical is often an element of shame, fear oestrogen and stigma associated with asking for For men: alpha adrenoceptors assistance, particularly from unfamiliar antagonists, 5-alpha reductase carers.7 Continence care is a recognised inhibitors activity that provokes anxiety among Electrical or magnetic stimulation Targeting posterior tibial nerve or cognitively impaired residents.12 sacral nerve Care in Australian RACFs is provided by Minimally invasive procedures Radiofrequency denaturation of a total workforce of 133,000 employees; the urethra, injection of periurethral these are nurses (registered or endorsed) bulking agents and personal care assistants,12 many of Surgery For women: sling procedures, whom are overseas-trained and bring colposuspension, urethropexy along their own set of culturo-ethnic For men: prostatectomy, artificial urinary sphincter, male sling and professional diversities. There is often minimal formal education about Passive Pads – disposable or reusable Urinals containment incontinence and its management, Catheters – urethral or suprapubic Bedpans which leads to varying levels of skill and Condom drainage Commodes experience. High turnover rates from Bed protection products difficulties in retaining skilled staff lead to *Specific treatment options may not apply to all types of urinary incontinence carers being unfamiliar with their working

500 AFP VOL.45, NO.7, JULY 2016 © The Royal Australian College of General Practitioners 2016 URINARY INCONTINENCE IN RESIDENTIAL CARE CLINICAL

Box 1. Indications for specialist of pads were common management with, and carers who themselves are care referral24,2 approaches; no studies aimed at of varying levels of skill and experience. maintaining continence.19 This speaks Clinical conditions Often, a patient’s preference on • Haematuria about the perceived irreversibility of continence care is sidelined for practicality • Suspected pelvic mass or urogenital the condition, which unfortunately of care to be provided on a daily basis. fistulae is often the case in residential care RACFs abide by a government-funding • Symptomatic prolapse where researchers and clients both model that ‘incentivises higher levels • Palpable bladder after voiding seem to have accepted this.7, 1 2 Goals of of incontinence’ causing some staff to • Persistent pelvic pain continence care needs to be discussed focus on ‘securing funding and avoiding • Suspected neurological disease with the resident or a surrogate decision sanctions’ rather than providing optimal • Voiding difficulty maker, taking into account what is care.22 Over-reporting of incontinence • Previous continence surgery or pelvic practically feasible for carers to provide. rates during particular assessment cancer surgery In a comparative study of residents, 22 • Poor response to conservative periods for funding is prevalent. A management family members and nursing staff, change from ‘rewarding’ higher rates of • Unclear type/diagnosis of incontinence residents preferred medications to incontinence to supporting efforts made Patient factors to consider diapers, keeping in line with reported to improve continence and manage • Severity of symptoms wishes of ‘feeling dry, being natural, incontinence is warranted. • Psychosocial impact of symptoms not causing embarrassment, being easy • Likelihood of future improvement and not resulting in dependence’.20 In Conclusion with therapy this case, the old adage of ‘start low, go Urinary incontinence in RACFs is • Goals and treatment preferences slow’ should prevail, given the potential prevalent and remains a challenge to • General fitness for invasive procedures for side effects in this already vulnerable manage. The dearth of research provides population. Anticholinergics can cause much ambiguity about best standard confusion, dry mouth and constipation, practice and more high-quality studies 15 challenges for carers. Poor access to and can interfere with the positive effects are needed to support implementation ancillary continence services (eg nursing, of cholinesterase inhibitors used for of treatment options. For the medical physiotherapy) further compounds the the treatment of dementia. The ‘new practitioner involved, an appreciation of problem. Although there is some early kid on the block’ that has yet to receive various factors and factions in RACFs promise, there remains an insufficient government subsidy is mirabegron, will increase the chances of success in body of evidence to suggest that bladder a beta-3 adrenoceptor agonist that providing satisfactory care. training should be mandatory treatment relaxes the detrusor smooth muscle, for urinary incontinence.16 thus increasing bladder capacity. It is Author For women, in general, pelvic floor as effective as anticholinergics and has David S Lim MBBS, Continence Fellow, Geriatrics Department, Eastern Health, Vic. muscle training (PFMT) remains first- a more favourable side effect profile, [email protected] line treatment for urinary incontinence but it should not be used in severe or Competing interests: None. 21 and can improve urinary symptoms and uncontrolled hypertension. Provenance and peer review: Not commissioned, QoL.17 However, those with cognitive Invasive procedures for diagnostic or externally peer reviewed. and functional impairment in RACFs therapeutic purposes remain unpopular Acknowledgements may struggle to perform PFMT. The among residents in RACFs. Detailed I would like to thank Dr Jonathan Marriott and majority of trials for PFMT revolve around discussions about potential benefits Dr Serena Wong (both consultant geriatricians, the perinatal period, and few studies versus the likelihood of adverse Eastern Health, Vic) for providing editorial support in preparing this manuscript. have focused on geriatric patients, outcomes need to be conducted prior to particularly those living in residential care making such decisions. References settings.16 There is a lack of good-quality It remains crucial that, whenever 1. Abrams P, Andersson KE, Birder L, et al. Fourth evidence that PFMT makes a positive possible, a resident is able to decide international consultation on incontinence recommendations of the International Scientific difference when it is added to another on their preferred treatment. In RACFs, Committee: Evaluation and treatment of active treatment for all types of urinary facility staff add a different dimension to urinary incontinence, pelvic organ prolapse, 18 and fecal incontinence. Neurourol Urodyn incontinence in women. the equation. This could involve different 2010;29(1):213–40. A systematic review investigating levels of the organisation, from executive 2. Hersh L, Salzman B. Clinical management the management of incontinence in management with particular financial and of urinary incontinence in women. Am Fam Physician 2013;87(9):634–40. residential care found that non-invasive regulatory interests, clinical managers 3. Chiarelli P. Continence assessment in residential methods involving toileting and use who have performance indices to comply aged care. Australas J Ageing 2011;30(1):2.

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