Promoting continence control in the frail elderly resident
Incontinence is a prevalent and costly problem in aged care, and poor management of incontinence impacts on the health and quality of life of the individual and the environment of the aged care home, writes Jacinta Miller.
Modern residential aged care (RAC) facilities are a far cry from the dark, inhospitable and odorous dormitory wards of institutions for the elderly that are a recent memory. Since the 1990s, reforms in the sector mean that modern facilities are more ‘home-like’ with private rooms and bathrooms, and the adoption of a resident-focussed model of care is closely linked to the aspirations of the sector, the requirements of families and the needs of the resident.
It has long been recognised that among the main reasons a person is admitted to RAC is the need for continence management. It is not uncommon for a carer to be able to fully care for a family member at home, up to the point that the person cared for cannot clean themselves after toileting, or requires full assistance to put on and change a pad or other appliance for containment of urinary or faecal incontinence.
In 1998, the year the National Continence Management Strategy (NCMS) was launched, then-Minister for Family Services, Warwick Smith stated, “Continence problems are a trigger for many older people being admitted to residential care”1. This was reiterated by Pearson and colleagues in a 2002 study into incontinence as a factor leading to RAC admission, who stated, “Incontinence was found to be a significant factor in decisions regarding admission to aged care homes, especially with admission to high level care homes”2. This is supported by international reports3.
The cost and prevalence of incontinence in aged care
To put the significance of incontinence in perspective, the Australian Institute of Health and Welfare (AIHW) reported in 2006 that 545,000 adult Australians (2.8 per cent of the population) experienced severe incontinence4. Severe incontinence has been quantified to mean involuntary leaking of urine of 75g or more over 24 hours5. Those living in RAC who ‘always or sometimes require assistance to manage their urinary or faecal incontinence’ numbered 128,800 and the statistics show the cost of managing incontinence in the sector was estimated to be $1.268 million and the cost of continence aids $111.7 million4. It is estimated that the combined cost related to urinary and faecal incontinence in Australia across the health and RAC system is around $1.5 billion and it is conceded that “…a wide range of personal costs such as laundry, clothing and time costs are generally not captured”4. By 2030 it is expected that RAC sector expenditure on continence management will rise by around 220 per cent4.
Incontinence is not necessarily normal in the ageing process, though age is regarded as a risk factor3. Residents in RAC settings who are reported to have severe incontinence usually have one or more co-morbidities with the largest diagnosis groups being dementia, stroke and muscular skeletal disorders, including arthritis3, 4, 5, 6. Such diagnoses make these residents more prone to incontinence due to physical or functional deficits. However, a general consensus is emerging that incontinence in the elderly is a ‘dynamic’7, treatable condition8, and women are twice as likely to be incontinent than men7.
Assessment and management of incontinence
We know that incontinence is a prevalent and costly problem in aged care, and poor management of incontinence impacts on the health and quality of life of the individual and the environment of the aged care home. In Australia, good incontinence management is mandatory if RAC facilities are to meet the standards for accreditation9 and funding10. While continence management is a specific outcome in Standard 2, it does cut across all four of the standards and includes, for example, outcomes relating to staff education, supplies, clinical care, behaviour management, skin health, infection control, complex care, privacy and dignity, leisure, activities, and the living environment. Care and care planning for continence management is specifically addressed in the Aged Care Funding Instrument (ACFI), which came into national use in March 200810. The ACFI requires proof for the claims for care and has made nursing competency in the assessment of residents and the availability of good assessment tools vital in the RAC sector.
While individual RAC facilities can adopt local assessment tools, there has been much research to develop and improve validated tools that capture the information required and are not onerous on RAC staff to complete. In 2004, researchers from Deakin University identified 76 resources used in RAC facilities for the assessment and management of incontinence, and reported none covered all key criteria for continence care in the frail elderly population11. Following this, the NCMS provided research funding for the development of a suite of continence assessment tools particular for use in RAC12. These were discussed at the National Conference on Incontinence in 2009 and published in March this year13. This suite of evidence-based tools dealing with urinary and faecal incontinence were developed to: address the 28 clinical symptoms and 15 factors contributing to incontinence; provide cues for assessment and management relevant to care plans; and address the diverse skill mix among staff in the RAC sector13. The forms are freely available on the Australian Government Department of Health and Ageing continence website www.bladderbowel.gov.au and include:
- Continence Management Flow Chart
- Continence Screening Form
- Three-Day Bladder Chart
- Seven-Day Bowel Chart
- Monthly Bowel Chart
- Continence Assessment and Care Plan Form
- Continence Review Form
Assessment and care planning are the foundations of good continence management and are continual and challenging. Continence management is as complex as the myriad of reasons a person may be incontinent in the absence of a urologic reason6. Reasons why a person may suffer incontinence could be as arcane as the person’s preference for care or containment product, that they wear a trouser with buttons, zip and belt, the toilet may not be obvious or difficult to access (i.e. behind a heavy door), or, in the case of some elderly rural residents, that the toilet is inside. The resident may be incontinent because they have an undiagnosed or diagnosed urinary tract infection, they are constipated, staff are unavailable, or due to the medicines the person is prescribed6, 7, 8, 14, 15.
Continence assessment begins with screening. O’Connell and colleagues recommend using a continence screening tool 48-hours post admission13 and if there is incontinence then the three-day bladder and seven-day bowel charts are completed. The data collected on admission prompts assessment and care planning. The value in assessment is how the information is used to treat and manage incontinence, as the goal of care of continence management, even in the frail elderly, is to achieve continence and independence8. DuBeau and colleagues reporting on the 4th International Consultation on Incontinence (ICI) Committee11, incontinence in the frail elderly, note that treatment choices are guided by comorbidity, remaining life expectancy and that personal preference with scheduled toileting, containment and medication are the top three management preferences8. According to the committee, “Even in cognitively impaired persons, one can elicit treatment preferences, evaluate domains of quality of life (e.g. social interaction), and assess treatment satisfaction directly or behaviourally”8.
Interventions to manage incontinence in RAC
The 4th ICI committee noted changes to models of incontinence care in the United States where there is now an emphasis on quality of care in the aged care sector in that country that mandates assessment over care plan documentation. The committee has made recommendations for management of urinary incontinence and lists specific interventions under the eight points: Basic assessment, Management principles, Lifestyle interventions, Behavioural therapy, Pharmacological therapy, Surgery, Nocturia, and Interventions with long-term care staff8. The committee noted that behavioural strategies including prompted voiding and schedule toileting were regarded as the mainstay interventions in the RAC sector; however, containment of urinary and faecal incontinence was the most used intervention by care staff8.
Behavioural interventions are the most accessible for residents and aged care staff no matter where the RAC facility is situated and are usually the first line of treatment along with containment strategies3, 8, 6, 14, 16.
Prompted voiding: This is a behaviour therapy for bladder retraining and was the subject of a Cochrane intervention review in 2009. Eustice and colleagues explain:
“Prompted voiding requires assisting a resident to walk, or be taken, to the toilet and is more labour intensive than practices that aim to suit available resources, such as changing protective pads after two or three incontinent episodes at the convenience of carers. It involves the education of both the person with incontinence and the staff, using a programme of scheduled voids that requires verbal prompting from the caregiver”16.
While the reviewers concluded that the evidence on the long-term efficacy of prompted voiding was slim, the studies included in the review suggested some short-term benefit and that this inconclusiveness really showed that more research was needed on the subject16. They also noted that this intervention took a lot of carer time, which may thwart its wider acceptance as an intervention in RAC facilities.
Scheduled or timed toileting: Assisting a resident to the toilet is one of the core activities of daily living that RAC staff provide. Timed voiding, sometimes referred to as scheduled, routine or regular toileting, was the subject of a Cochrane intervention review in 200417 in which it was described as an intervention in which there is a fixed interval of time between toileting. It is generally considered a passive toileting assistance program that is initiated and maintained by a caregiver. The goal of this intervention is to avoid episodes of incontinence rather than restoration of bladder function and it is aimed to achieve continence by anticipating involuntary bladder emptying and by providing regular opportunities for elimination17. While this review also found the evidence for this intervention inconclusive it again recommended that more robust studies were needed.
Prompted voiding and scheduled toileting are the main interventions used by care staff to maintain continence and dryness for ambulant residents. Often, a resident’s wandering behaviour may be linked to them needing to void or move their bowel. By being aware of individual resident behaviour cues, carers can provide good continence control. Urinary assessments including bladder diaries, such as the three-day bladder chart, can provide carers with information about elimination patterns particular to each resident. Such patterns could show that a particular resident will usually void or have a bowel movement at a particular time of the day and so the carer can either prompt the resident to use the toilet or schedule toileting at those times.
Use of absorbent products: Containing urine leakage using some type of absorbent padding has historically been the first recourse of patients to self-manage episodes of incontinence. Those working in the home nursing sector will no doubt be able to recount the creativity of their clients in this area. Prior to the mid-1980s in Australia, containment meant using washable pads either worn or used on chairs and beds. Disposable absorbent pads became widely used due to advances in the non-woven fabric industry and the development of super absorbent polymers, and today disposable absorbent products for adult incontinence is the largest growing market of personal hygiene care18.
There are several Cochrane reviews relating to use of absorbent pads to contain urinary incontinence but for our purpose, looking at interventions for severely incontinent frail elderly residents, the 2008 review into Absorbent products for moderate-heavy urinary and/or faecal incontinence in women and men19 is most relevant. Fader and colleagues defined moderate-heavy incontinence as urine or faecal loss requiring a pad with absorbent capacity of 2000g to 3000g19. They identified “…four main designs of body-worn absorbent products used for moderate-heavy incontinence (i.e. urine or faecal loss that can be contained within a large absorbent pad); disposable pads (sometimes called insert pads) worn with stretch pants, disposable diapers (like babies’ nappies), disposable T-shaped diapers (like diapers with a waist-band) and pull-ups (like toddler training pants); there are also washable versions of these. In addition, disposable and washable underpads/bedpads and chairpads may be used, usually to provide ‘back-up’ for body-worn pads”19. The reviewers noted that there was different acceptance and preference of disposable products between women and men, which has implications for continence management in RAC and that choice of product was important for containment with people requiring different products for day and night. There are also cost factors associated with the choice of product and in delivery of care14. The implications of continence containment on skin health20 and consumer preference is also driving industry innovation and development of disposable products18.
Listening to residents, or observing their behaviour when they are wearing an incontinence aid, can help carers select the most appropriate product and support a resident’s autonomy. Many are there times, for example in a dementia unit, that the sewerage blocks because a resident has flushed a pad inserted into their underwear down the toilet, or staff search and search for the source of an odour when a resident has soiled a pad and hidden it. In these cases, incontinence aids such a pull-up pants that look like underwear may be the most appropriate and most acceptable to the resident.
Implications of poor incontinence management
The problems associated with poor management of incontinence include physical pain, propensity to fall, adverse or aggressive behaviours21, 22 and risk of skin infections23. Due to poor management of incontinence, the individual will lose their independence, may be isolated in the RAC facility due to being embarrassed, ostracised for having an odour, or be unable to participate in activities or outings, which compounds low self-esteem, loneliness, and feelings of depression24, 25.
It also follows that poor continence management practices add to the costs incurred by RAC facilities, including the following: higher costs relating to disposable incontinence containment aids where continence aids are inappropriately applied or inappropriate for the resident; costs of complex nursing care for example due to skin infections; increased laundry costs; increased cleaning costs; and wear and tear on furniture and mattresses.
Points for practice
Experienced carers are attuned to the sights, sounds and smells of their residents, and are quick to pick up the signals from new residents that continence elimination may be an imminent issue. If a resident is wandering or agitated, carers will usually steer them to the nearest toilet and if a resident is aggressive, either verbally or physically, then constipation and urinary tract infection are first ruled out before other remedies are sought. By providing the opportunity for a person to sit on a toilet many problems such as incomplete bladder emptying and constipation can be avoided.
Other points include:
- Complete continence assessments on admission and review periodically or if there are changes in urinary or faecal elimination habits.
- Use continence assessment to inform strategies including scheduled toileting.
- Even if a resident wears an incontinence aid, scheduled toileting may be effective to promote dryness and to reduce the consumption of disposable pads.
- Treat symptomatic UTI as soon as possible.
- Ensure the resident has regular bowel habits and appropriate aperient regimen.
- Listen to the resident or observe the resident and provide the most appropriate intervention or incontinence aid.
Supporting continence management in RAC
The Continence Foundation of Australia (CFA) offers accredited courses and workshops in continence management suitable for those working in the RAC sector. The CFA supports and promotes World Continence Week (this year held in June), and the annual National Conference on Incontinence offers a variety of workshops and presentations relevant to aged care. Under the National Continence Program, the CFA offers scholarships for conference attendance. In 2011, the 20th National Conference on Incontinence will be held in Melbourne from 16th to 19th November.
The CFA provides free resources and information, including resources in 20 non-English languages, on many continencerelated topics relevant to RAC and the care of residents. It also manages the National Continence Helpline (1800 33 00 66). For further information visit the CFA website at www.continence.org.au or www.bladderbowel.gov.au
1. Smith W $15 million for National Continence Management Strategy. Media Release 10 June 1998. URL: http://www.health.gov.au/http://www.health.gov.au/internet/main/publishing.nsf/Content/health-archive-mediarel-1998-ws4498.htm (accessed 20 May 2011).
2. Pearson J, Finucane P, Tucker I, Bolt J, Kelly S, Eastwood S, Wilson S & Kong J. Incidence of Incontinence as a Factor in Admission to Aged Care Homes. 2002 Report prepared for the Australian Government Department of Health and Ageing.
3. Griebling TL. Geriatric urology. 2004 URL: newfrontiers.americangeriatrics.org/chapters/pdf/rasp_10.pdf (Accessed 20 May 2011).
4. Bricknell S, Goss J & Mann N. Australian incontinence data analysis and development. Australian Institute of Health and Welfare (AIHW) 2006. AIHW cat. no. DIS 44. Canberra: AIHW.
5. O'Sullivan R, Karantanis E, Stevermuer TL, Allen W & Moore KH. Definition of mild, moderate and severe incontinence on the 24-hour pad test. BJOG. 2004; 111(8): 859–862.
6. Gomelsky A & Dmochowski RR. Urinary incontinence in the aging female Aging Health 2011; 7(1):79-88.
7. Byles J, Millar CJ, Sibbritt DW & Chiarelli P. Living with urinary incontinence: a longitudinal study of older women. Age and Ageing. 2009; 38:333-8.
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9. Aged Care Accreditation Agency. Accreditation Standards available: URL: http://www.accreditation.org.au/accreditation/accreditationstandards/
10. Aged Care Funding Instrument (ACFI) Australian Government Department of Health and Ageing. URL:http://www.health.gov.au/>http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-acfi-aboutacfi.htm
11. Day K, Hunt S, O’Connell B, Jennings H, Ostaszkiewicz J, Crawford S & Hawkins M. The evaluation of continence resources used in Australian residential aged care facilities (Abstract). ANZCJ. 2004;10(4): 97.
12. O’Connell B, Ostaszkiewicz J, Hawkins M & Gilbee A. Trial and evaluation of a suite of continence assessment tools for residential aged care (Abstract) ANZCJ. 2009;15(4):101.
13. O'Connell B, Ostaszkiewicz J & Hawkins M. A suite of evidence-based continence assessment tools for residential aged care. Australasian Journal on Ageing. 2011;30(1):27–32.
14. O'Connell B, Ostaszkiewicz J, Day K. The challenge of managing continence care in residential aged care settings: recommendations for research and practice. Geriaction. 2005; 23(3):5-18.
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16. Eustice S, Roe B & Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002113. DOI: 10.1002/14651858.CD002113.
17. Ostaszkiewicz J, Johnston L & Roe B. Timed voiding for the management of urinary incontinence in adults. CochraneDatabase of Systematic Reviews 2004, Issue 1. Art. No.: CD002802. DOI: 10.1002/14651858.CD002802.pub2.
18. Bell I. Incontinence, An Embarrassment Of Riches. March 2011 URL:http://www.nonwovens-industry.com/articles/2011/03/inconti
19. Fader M, Cottenden AM & Getliffe K. Absorbent products for moderate-heavy urinary and/or faecal incontinence in women and men. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD007408. DOI: 10.1002/14651858.CD007408.
20. Beguin A-M, Malaquin-Pavan E, Guihaire C, Hallet-Lezy A-M, Souchon S, Homann V, Zöllner P, Swerev M, Kesselmeier R, Hornung F & Smola H. Improving diaper design to address incontinence associated dermatitis. BMC Geriatrics. 2010;10:86.
21. Hall KA & O'Connor DW. Correlates of aggressive behavior in dementia. International Psychogeriatrics. 2004;16:141-158.
22. Leonard R, Tinetti ME, Allore HG & Drickamer MA. Potentially modifiable resident characteristics that are associated with physical or verbal aggression among nursing home residents with dementia. Archives of internal medicine. 2006;166(12):1295-1300.
23. Farage MA, Miller KW, Berardesca E & Maibach HI. Incontinence in the aged: contact dermatitis and other cutaneous consequences. Contact Dermatitis. 2007; 57: 211–217.
24. Ko Y, Lin S-J, Salmon JW & Bron MS. The Impact of Urinary Incontinence on Quality of Life of the Elderly. Am J Manag Care. 2005;11:S103-S111.
25. de Rooij A, Luijkx KG, Declercq AG & Schols J. Quality of life of residents with dementia in long term care settings in the Netherlands and Belguim: design of a longitudinal comparative study in traditional nursing homes and small scale living facilities BMC Geriatrics. 2011;11(20). URL: http://www.biomedcentral.com/1471-2318/11/20
Jacinta Miller is the editorial coordinator of the Australian and New Zealand Continence Journal and a Registered Nurse in rural acute and aged care at East Wimmera Health Ser vice (Wycheproof Campus, Victoria).
The Continence Foundation of Australia is the national peak body for continence promotion, management and advocacy. It provides a wide range of services including the National Continence Helpline, accredited training in Continence Promotion and Care and the National Conference on Incontinence.
The National Continence Helpline (1800 33 00 66) is a telephone advisory service that is available to all Australians, Monday to Friday, from 8am to 8pm AEST. The Helpline supports a wide range of health professionals including those working in residential aged care.
The Helpline also provides a wide range of information resources, including resources in 20 non-English languages. For further information visit www.continence.org.au
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