Continence Care in Residential and Nursing Homes

Assessment

Although thorough assessment by a nurse or doctor leads to a diagnosis of the case of incontinence and is the key to appropriate continence management, the home care staff can make a valuable contribution through the following:

Patients/carers own view of the main problem (gives some measure of the patient's co-operation with treatment regimes:

• Severity - this is the amount of wetness and the impact it has on the patient, such as frequent calls to the toilet or the distress it causes the patient.
• Bothersomeness
• Attitude to the problem

Frequency volume chart

A record (chart) of intake, measured volumes voided and incontinent episodes will:

• Confirm patient/carer history.
• Identify amount of fluid intake.
• Identify minimum and maximum volumes voided during daytime and nighttime.
• Identify frequency of voiding, and incontinence episodes.
• Highlight any pattern associated with the incontinence episodes.

Medical conditions associated with incontinence

• Infection - not only of the urine but also of the skin between the legs, the commonest of which is a fungal infection in which the skin is red and moist.
• Oestrogen deficiency - very common in elderly ladies, causing urinary urgency and a sore, dry vagina.
• Diabetes - often associated with incontinence.  Check for the presence of glucose in the urine.
• Neurological disorders such as stroke or multiple sclerosis - affect central nervous system control of bladder and sphincter.
• Previous pregnancies - difficult deliveries, may result in prolapse or nerve damage.

Older people frequently have many different things wrong with them and are taking lots of tablets and medicines which, in themselves, can contribute to urinary incontinence or make its management more difficult. Although  incontinence is not inevitable, it is much more common if the patient is severely confused and physically disabled.  It follows that correction of confusion or active rehabilitation will reduce incontinence.

Psychological conditions associated with incontinence

• If the patient has a learning disability was there any previous treatment for the incontinence and what was its effect?
• Is the patient depressed leading to demotivation?
• Is the patient anxious increasing urinary urgency and frequency?
• Is the incontinence worsened by, or causing, anxiety/depression?

Social factors

• How does incontinence affect social activities?
• Does patient avoid visitors/outings?
• Does incontinence improve with visitors/outings?

Factors which aggravate or precipitate incontinence

Bowel function

An overloaded bowel is not always obvious, but it is a very common cause of incontinence.  Always check by rectal examination, particularly if faecal incontinence or soiling occurs.  It is important to note on a chart what the bowel pattern is.

Mobility/dexterity

How has the patient been coping around the home?
Observe ability to reach the toilet, manage clothing and get on/off WC.  If  help is required the patient cannot be continent unless the help is provided.

Medication

Review need for and effectiveness of medication, especially:

• Diuretics, such as frusemide and bendrofluazide, which increase the amount and speed of urine produced.
• Anticholinergics, such as anti-parkinsonism drugs, anti-depressants and oxybutynin which may precipitate poor bladder emptying or retention.
• Sedatives, such as temazepam, which may reduce awareness of the need to pass urine and increase confusion.

Diagnosis

Different causes require different treatments and therefore and accurate diagnosis is important.  It can be made by the patient's doctor or specialist continence nurse.  The treatment of urinary incontinence is relatively straight forward once a diagnosis is made.  It is quite appropriate to make the initial diagnosis clinically on the basis of symptoms and signs.  Begin by identifying the onset of incontinence, what treatments have been tried and how the patient copes with the problem.

The main causes of incontinence are:

• Urge incontinence (detrusor overactivity). In this condition the patient is unable to prevent involuntary bladder contractions, which cause urgency with little or no warning of incontinence.  The sufferer may respond to this urgency by frequent visits to the toilet day and night.  Urge incontinence is often made worse by anxiety or fast bladder filling, for example after diuretic medications.
• Stress incontinence (pelvic floor weakness). A small leakage of urine occurs on physical exertion such as standing, lifting, coughing or sneezing, and rarely occurs during sleep at night.  This is the commonest cause of incontinence in middle aged women and is seen in some men after prostatectomy.
• Overflow incontinence (retention of urine). The patient will have a large post-void residual urine volume and may complain of continuous dribbling incontinence or symptoms like stress incontinence.  Recurrent urinary tract infections are common and the condition is made worse by constipation or anticholinergic medication.  Overflow incontinence can be caused by diabetes and some types of nerve damage.  It also occurs in men with prostatic obstruction.
• Outflow obstruction. This almost always occurs in men, who may complain of difficulty in starting micturition, poor urinary stream and dribble after micturition, perhaps with a feeling of inadequate emptying.
• Functional incontinence (e.g. poor or painful mobility, loss of dexterity, impaired communication, mental confusion and depression). Incontinence is due to inability to reach and use the toilet.

Management

Having carried out the assessment and corrected obvious problems (e.g. fluid intake, constipation and urinary tract infections) consider the following:

Absorbent body worn pads

Body worn pads are bulky and in a home with many incontinent residents they can provide difficulties with storage space disposal.  Washable pants with an integral pad may be sufficient for light urinary incontinence, and easier for the patient to manage alone.

Properly used, pads can help to maintain dignity and independence, but they can lead to dependence on 'mopping up' and an acceptance that incontinence is expected in the elderly and irreversible.

A continence products directory is available from the Continence Foundation.  Pads are not available by prescription (FP10), but they are available either through the Community Nursing Services or Social Services (in Scotland they are provided to residential and nursing homes via the Health Service).

Toileting regimes

If the patient is sensible bladder retraining with the help of the specialist continence nurse is the appropriate treatment.  Patients unable to co-operate require a regular toileting programme which aims to ensure bladder emptying before incontinence occurs.  This will be different for each patient, and the optimum time between visits to the toilet should be identified using a voiding record, e.g. a short toileting time may be instigated initially, and progressively lengthened depending on results.

Catheters

Catheters are not always successful in managing incontinence but may be necessary if the patient has persistent urinary retention.

Bacteriuria, chronic urinary tract infection and urethral damage are always associated with long term indwelling urethral catheters.  Recurrent blockage with debris/crystals is common and later complications include the formation of bladder stones.

Leakage may occur around the side of the catheter and so not resolve the problem.  Discomfort and odour causes distress to the patient.

Indwelling catheters deny patients the opportunity to void 'normally', making a return to continence unlikely.

Intermittent catheterisation is a preferable form of emptying the bladder and should be considered if the patient has the mental capacity and dexterity to carry it out.  If not, care staff should consider carrying this out in preference to a long term indwelling catheter.

All catheters and urine drainage bags are available on prescription.

Every patient who has an indwelling catheter requires a daily warm soapy wash of the whole genital area (or a bath or shower).

Sheaths

These are external devices for men.  They do not suffer from the complications of catheters but the penile skin may become sore.  Fitting of the correct size is important, and shaving around the base of the penis improves contact.

Other aids and equipment

A variety of aids to collect urine, and to prevent urine leakage are available which may assist continence for individual patients.  The occupational therapist/community nurse may be able to advise.

Referral for specialist advice

Although most Health Authorities/Health Boards have a specialist doctor or nurse with an interest in the treatment of incontinence not all patients are appropriate for such referral.  However it is always better to ask than to assume nothing can be done.

Many older residents, particularly those with dementia, find a visit to hospital distressing and so this should only be considered when a thorough assessment and appropriate conservative treatment have been found unsuccessful in the home.

Clinical nurse specialists in incontinence usually provide the first step in a referral process.

Educational programmes

A programme of basic education on continence promotion is essential for all staff working with elderly residents.  A method of ensuring this is to nominate one person to develop a special interest, and to act as a resource for other staff.

The Association for Continence Advice exists to provide information, advice, education and support to all healthcare workers and membership is available to individuals or groups.