End of Life Care in Frailty: Continence care

There is a paucity of evidence for continence care at end of life.¹ Continence issues are common, although many people are continent until the terminal stages. However urinary and faecal incontinence are conditions affecting one in three people living in residential care, and two in three nursing home residents.² The prevalence of faecal incontinence rises with age and accounts for more than 40% of residents,³ while 72% of patients with dementia have urinary incontinence in their final year of life.⁴ Loss of bladder and bowel control is linked to considerable discomfort, distress and sometimes pain.⁵ Thus, the promotion of dignity, comfort, patient preferences and environmental considerations are paramount and should be incorporated into routine care.⁶ While preventable causes should be identified, treatment needs to be weighed by the benefit as well as burden to the individual.

Promoting dignity, modifying the physical space and the wider involvement of the MDT and family is foremost in continence care at end of life for older people with frailty. Thorough assessment and ongoing monitoring of continence issues often makes the difference between informal carers being able to manage at home and admission to acute or nursing home care. This is especially important for people with cognitive as well as physical frailty. Difficulties with recognising the signals to void, getting to the right place and then emptying once in position means extra vigilance in assessment and management of continence issues in people with dementia.

Causes and management

Core causes and management across continence care include:

• Mobility: Lack of exercise leads to immobility and poorer general health, and functional dependency increases near the end of life. Individualised exercise programmes, including balance, can improve getting to and sitting on the toilet.
• Ability: Consider the ability of the individual to hygienically clean, remove and replace clothing.
• Environment: Assessment of environment by Occupational Therapist, including access to toilet, toilet adaptation, privacy, provision of toilet substitutes (e.g. urinals/commodes) with awareness of privacy, dignity and individual preferences, provision of odour control. The availability and readiness of of carers to respond if help is needed should be considered, as well as aids to mobility, toileting and hygiene as appropriate.
• Skin care: As needed to avoid soreness.
• Continence products including mattress protection: Incontinence pads may be the least invasive option. (See resources for advice to healthcare professionals and carers or patients regarding choices).
• Carers: Availability, ability and willingness to assist with personal hygiene.
• Dietary and fluid intake: Ensure adequate hydration and diet - especially soluble fibre (possible dietetic involvement). Adequate hydration but not excessive - approximately 1500ml per day.
• Bowel/fluid and food charts: To assess intake and guide treatment.

Constipation

Constipation may be asymptomatic but can cause uncomfortable symptoms including nausea and vomiting, abdominal pain and distension, urinary retention, overflow diarrhoea and bloating. These symptoms can mimic bowel obstruction⁷ (see Table 1) and at times precipitate hospitalisation. Constipation is a major cause of admission to acute care from nursing homes.⁸

Urinary incontinence and faecal incontinence

Promoting continence care is often aimed at maintaining comfort and dignity and relieving symptoms, not overly aggressive investigation and invasive treatments. Faecal incontinence is particularly distressing as incontinence pads are only a temporary support (if useful at all), and the damage to the skin and odour causes escalating discomfort and loss of dignity (see Table 1).

Table 1. Symptoms, causes and management in continence care of older people at the end of life

References

1. Farrington N, Fader M, Richardson A. Managing urinary incontinence at the end of life: an examination of the evidence that informs practice. Int J Palliat Nurs. 2013;19(9):449-56.
2. British GSJWP. Quest for Quality - An Inquiry into the Quality of Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Improvement; 2011.
3. Musa MK, Saga S, Blekken LE, Harris R, Goodman C, Norton C. The Prevalence, Incidence, and Correlates of Fecal Incontinence Among Older People Residing in Care Homes: A Systematic Review. Journal of the American Medical Directors Association. 2019.
4. McCarthy M, Addington‐Hall J, Altmann D. The experience of dying with dementia: a retrospective study. International Journal of Geriatric Psychiatry 1997;12(3):404-9.
5. Smith N, Hunter K, Rajabali S, Fainsinger R, Wagg A. Preferences for continence care experienced at end of life: a qualitative study. Journal of pain and symptom management. 2019;57(6):1099-10 e3.
6. Health NIf, Excellence C. Care of dying adults in the, last days of life (NG31). NICE London; 2015.
7. Scottish Palliative Care Guidelines: Symptom control (constipation). Available at: www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Cons....
8. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010;50(5):625-63.
9. Chokhavatia S, John ES, Bridgeman MB, Dixit D. Constipation in elderly patients with noncancer pain: focus on opioid-induced constipation. Drugs & Aging 2016;33(8):557-74.

Resources

• Algorithms for management of urinary incontinence and faecal incontinence in older people with frailty
• NHS England: Excellence in Continence Care
• BGS: Continence care in residential and nursing homes
• Scottish Palliative Care Guidelines: Symptom control (constipation)
• Bladder and Bowel UK
• Continence Product Advisor