Incontinence management in older people: A wake-up call

Mathias Schlögl (MD, MPH) specialises in internal and geriatric medicine. One of his clinical and research interests is communication. He works at the University Clinic for Acute Geriatric Care at the City Hospital Waid in Zurich, Switzerland and is a recent graduate student from the European Academy of Ageing (EAMA). Adam Gordon is Professor of Care of Older People at the University of Nottingham and President Elect of the British Geriatrics Society. Here they discuss their recent commentary HEARTS, minds and souls – it’s time for geriatricians to bring more to continence management in Age and Ageing @Age_and_Ageing.

Current urinary incontinence (UI) guidelines often mention older adults with frailty but the detail and nuance of continence care for this group are not often well described. Supporting older people with urinary incontinence takes time and can be resource-intensive. If guidelines are to be useful in underpinning service development and clinical practice, they need to consider the specific care of older people in greater detail.

In our recently published paper in Age and Ageing, we have focused on bringing well-established communication techniques from the care of older people together as a mnemonic, which can help guide consultations for older people who present with continence issues. The HEARTS mnemonic is designed to remind us that good communication in care of older people should be responsive, empathetic, individualized, person-centred, and devoid of ageism.

Humanity

• Open the conversation with those who do not have self-declared symptoms in a sensitive manner, avoid ageist assumptions, attend to the balance of technical and emotional content, and respond to continence care needs in a timely manner.

Empathy

• Acknowledge the stigma associated with UI and recognize the fear and uncertainty related to the ageing process.

Autonomy

• Seek to understand older adults’ cultural beliefs and values, adopt a relationship-centred approach and work hard to protect and respect autonomy in decisions for those with cognitive impairment.

Respect

• Cultivate an unrushed consultation style and remember that small gestures to maintain personal dignity truly matter.

Trust

• Know and understand a person’s biography and personalize your approach to care by showing that you are trying to accommodate their values and beliefs.

Shared planning

• Engage in shared decision making and ensure that a management plan with the full range of potential therapies for patients and their families is established.

These principles are not unique to urinary incontinence, but the principles apply well in this context.

Complexity in continence management of older people extends beyond communication.  Comprehensive Geriatric Assessment (CGA) is an evidence-based approach – multidisciplinary, multidomain assessment to drive a coordinated and iterative approach to care delivery – that works well in the context of continence care. But, by comparison with other “Geriatric Giants”, there has been little focus on how to implement CGA for older people with bladder or bowel problems.

It is clear that there are a number of barriers to implementing principles of good geriatric medicine into continence care.  These include limited investment in training specifically around continence management in older people, and the fact that older people are mentioned only in passing in many continence guidelines.

We started this blog, and our article, talking about HEARTS – but maybe our minds and souls are required too if we’re going to make continence care for older people as good as it can be.