End of Life Care in Frailty: Continence care

Clinical guidelines
British Geriatrics Society
Date Published:
12 May 2020
Last updated: 
12 May 2020

The aim of this guidance series is to support clinicians and others to consider the needs of frail older people as they move towards the end of their lives and help them to provide high quality care.

This chapter examines the management of continence issues in frail older people at the end of life. Please click here to view the other chapters in this series.

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.

  • 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 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

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


Causes to be aware of



  • Medication: opioids (e.g. codeine, morphine, oxycodone, fentanyl); antacids and diuretics; iron. Constipation resulting from opioid pain management alone (OIC) is estimated to affect 40–86 % of patients being treated for non-cancer pain and cancer-related pain. Studies suggest that OIC in older people is often under-recognised and undertreated.9
  • Direct effects of illness: tumour or metastasis in, or compressing, bowel wall; end stage Parkinson’s disease where the bowel is very slow; neurological or metabolic causes.
In addition to addressing diet, hydration and toilet access (sitting comfortably with feet well supported):
  • Prescribe laxatives - Bowel chart/stool type recorded to guide assessment and treatment.
  • Medication review.
  • Investigations and treatment for underlying causes.
  • Consider spinal cord compression/bowel obstruction.
  • Medications (e.g. laxatives, antibiotics, and NSAIDs).
  • Spurious diarrhoea due to faecal impaction.
  • Infection (e.g. C Difficile).
  • Dietary intolerance.
  • Medical conditions (e.g. rectal cancer) and/or treatment side effects; radiation colitis, small gut syndrome secondary to surgery.
  • Consider bowel obstruction.
  • Check not impacted.
  • Medication review; stop laxatives, start Loperamide in some cases (with careful monitoring to avoid constipation).
Urinary incontinence and faecal incontinence
  • Medications: high dose diuretics, drugs that cause urinary retention, caffeine is a bladder and bowel stimulant.
  • ‘Direct’ effect of ageing on the lower urinary tract.
  • Long-term problems with overactive bladder secondary to neurological issues, e.g. post stroke, idiopathic, neurogenic.
  • Urinary tract infection.
  • Pelvic floor weakness.
  • Constipation (can lead to more urgency).
  • Infection: increased risk of urine infection due to immobility, malnutrition and/or immunosuppression.
  • Rule out UTI.
  • No national guidance exists regarding the use of indwelling catheters (IC). A catheter may help to relieve agitation for some patients (protect skin and reduce unwanted movement) while others may find a catheter distressing. However, evidence does suggest long-term catherisation invariably leads to infection. Decisions need to take account of individual preferences, needs and environmental support.
  • Avoid antimuscarinic drugs in older people as risk dry mouth, constipation and can take up to 12 weeks to work.
  • Faecal incontinence: regulating defecation as a last resort may include using loperamide with suppositories.
  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.

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