British Geriatrics Society

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Continence Care in Residential and Nursing Homes

A Guide for those working in residential and nursing homes


Throughout the UK there has been rapid expansion in residential and nursing home care for elderly people, with a corresponding reduction in long-term hospital care.  Many of the residents are likely to have some degree of urinary incontinence or dysfunction.  Urinary incontinence in this setting should not be viewed as inevitable.  In the first instance, with good management it may be preventable.  Incontinence is a symptom of underlying problems which with simple assessment and investigation, can be identified and treated.  Even when a cure is not achievable, optimum methods of incontinence management can produce 'social continence', alleviate embarrassment of preserve patient dignity.

The aim of this document is to provide a brief guide for carers and nurses in residential and nursing homes.  We hope that this will assist you in planning individual care for each resident, and provide a framework within which improved continence care can be provided for both men and women.  A suggested reading and reference list is provided at the end.

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 measureof 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.

Elderly 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.

IMPROVING CARE : A SUMMARY.

Residents in long term care settings have special needs.  The standard of continence care provided varies between each area and between homes. Some or all of the following suggestions may already be achieved locally.  Others may take time, planning and resources.  All are within reach.

  • Every resident with urinary symptoms or incontinence should have an holistic assessment.
  • Community support should be available from experienced health professionals (such as a Clinical Nurse Specialist) so that patients and relatives may obtain information and advice, and educational programmes for nursing and care staff may be established.
  • Each home should have policies which promote continence for residents and ensure access to specialist community care where appropriate.
  • Patients whose problems cannot be resolved within the community should be considered for referral for further investigation, treatment and advice on management.
  • Regular audit of the management of incontinent residents in long term care settings should be undertaken, and the findings acted upon to improve standards of care.
  • Standards of incontinence care for residents in nursing and residential homes need to be established.  This will require liaison between community and hospital health professionals, particularly those who care for these patients generally (the GP and District Nurse) and those with expertise in incontinence (the Geriatrician and Clinical Nurse Specialist).  This may also involve national organisations such as the Continence Foundation.
  • A Clinical Nurse Specialist for the elderly should be employed to visit all nursing and residential homes regularly to review patient management and staff education programmes.

Further Reading


Books and Reports
1.    Brocklehurst N, Spurgeon P, Clark J (1995).  The nursing contribution to purchasing: case studies in continence care.  Health services management centre, University of Birmingham.
2.    Hunt S (1993) Promoting Continence in the Nursing Home.  Continence Foundation of Australia.
3.    Norton C (1995) Commissioning Continence Service: Guidelines For Purchasers.  London.  The Continence Foundation.
4.    Norton C (1996).  Nursing for Continence (Second Edition) Beaconsfield.
5.    Rhodes P, Parker G (1994) The role of continence advisers in England and Wales.  Social Policy Research Unit, University of York.
6.    Royal College of Physicians (1992).  The CARE Scheme (clinical audit of long term care of elderly people).  Royal College of Physicians of London.
7.    Royal College of Physicians (1995).  Incontinence: Causes, management and provision of services.  Report of the Royal College of Physicians.  Pub. Royal College of Physicians of London.
8.    Sanderson J (1991) An Agenda Of Action On Continence Services.  Department of Health, Community Services Division.

Journal Articles
1.    Brocklehurst J (1990) Constipation And Faecal Incontinence. Nursing the Elderly, 2(2):17-18.
2.    Brocklehurst JC (1993).  Urinary incontinence in the community - analysis of a MORI poll.  British Medical Journal, 306:832-4.
3.    Campbell-Stern C, Jagger C, Clark M, et al (1993) Residential care for elderly people: a decade of change.  British Medical Journal, 306:827-830
4.    Firth J (1996).  Containing Continence (Purchasing issues) Fundholding, 33-36.  June 5.
5.    McGrother C, Castleden CM, Duffin H, Clarke M (1987) Do the elderly need better incontinence services?  Community Medicine, 9(1): 62-67
6.    O'Brien J, Austin M, Sethi P, O'Boyle P (1991) Urinary incontinence: prevalence, need for treatment and effectiveness of intervention by nurses.  British Medical Journal, 303: 1308-12
7.    O'Brien J, Long H (1995) Urinary incontinence: long term effectiveness of nursing intervention in primary care.  British Medical Journal, 311: 1208
8.    Ouslander J, Schnelle J, Simmons S, et al (1993).  The dark side of incontinence: night-time incontinence in nursing home residents.  Journal of American Geriatrics society, 41: 371-376.
9.    Peet SM, Castleden CM, McGrother CW, Duffin HM (1995).  Prevalence of urinary and faecal incontinence in hospitals and residential and nursing homes for older people.  British Medical Journal; 311: 1063-1064
10.    Peet SM, Castleden CM, McGrother CW, Duffin HM (1996).  The management of urinary incontinence in residential and nursing homes for older people.  Age and Ageing; 25: 139-143.
11.    Rooker J (1993) Continence in the community.  Care of the Elderly, March p94.
12.    Tobin GW, Brocklehurst JC (1986) Faecal incontinence in residential homes for the elderly: prevalence, aetiology and management.  Age and Ageing, 15: 42-46

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