Targeting Our Approach to Incontinence

BY LEAH KLUSCH

I have never forgotten her image in the doorway.

All long-term care facilities need to view urinary incontinence as a prevalent condition that requires operational, clinical, strategic, and interdisciplinary focus. Costs of incontinence to the facility can include absorbent products, laundry, and increases in staff workload. There are also negative clinical, psychosocial, payment, and regulatory outcomes, as well as negative resident events such as falls, urinary tract infections, skin breakdown, depression, and repeated hospitalizations.

The numbers vary, but high percentages of residents are incontinent, even though urinary incontinence is not necessarily a normal part of aging. However, the American Medical Directors Association (AMDA) clinical practice guidelines state that the prevalence of urinary incontinence increases with age and affects women more than men. It can be treated, modified, managed, and cured-even in frail elderly individuals-although the cost of treating it is staggering: as high as $25 billion annually.

Incontinence is identified by observation or direct reporting from the resident. All involuntary loss of urine, including bed-wetting, is considered incontinence. The MDS 2.0 Users’ Manual (December 2002), Chapter 3, Section H, states: “If the resident’s skin gets wet with urine, or if whatever is next to the skin (i.e., pad, brief, underwear) gets wet, it should be counted as an episode of incontinence-even if it is just a small volume of urine, for example, due to stress incontinence.”

Most facilities are not, in fact, identifying residents with small to moderate amounts of urine loss caused by various types of incontinence (table 1). The current MDS database shows a much lower than expected number of residents coded with incontinence. If a resident is not identified appropriately as incontinent, then the care plan is wrong, and planned care interventions will not be adequate to meet the resident’s needs.

Managing incontinence is not just a clinical or nursing care issue. Other factors come into play, such as the resident’s history. Is it an old problem or a new problem? What was the impact of the hospital stay on the resident’s continence? A significant number of residents come to post-acute care facilities with a loss of bladder control because of the use of catheters in the hospital. Placement of an indwelling catheter during hospitalization or repeated catheterizations during a hospital stay can bruise, stretch sphincters, or cause other trauma to very delicate tissues.

Can we improve the resident’s ability to toilet independently or with minimal assistance? Restorative nursing programs need to be involved in initiating proper bladder retraining and toileting programs and then must monitor the programs as residents’ function improves. A properly designed retraining or scheduling program requires the involvement of the entire team and must be evaluated by professionals with significant education in this area. The use of consultants is important in this field, especially since new programs, research, and interventions are being developed all the time. Individualization of the program is essential, and communication of the interventions to the resident must be clear and easy to understand.

If the resident needs absorbent products, what is the best product to use? It is important to realize that some residents need more than one type of product during the day and night, and that all residents come in varying shapes and sizes. Table 2 includes factors to consider when choosing a supplier for these products.

Research in this field has identified several guidelines for appropriately managing incontinence in the nursing home (see “Recommended Guidelines,”).

As long-term care professionals focus on outcomes, quality of care, quality of life, and individualization of services, the problems presented to them involving incontinence are global and operational. It takes all the members of the facility team to identify the issues, provide the services, and select the proper products. This coming spring, AMDA will be releasing new clinical practice guidelines for incontinence care that will bring new information to our physicians and nurses, to help them to grow in knowledge and understanding of this problem. Until then, facilities need to identify the areas of operations and clinical services that they can develop to focus on the comprehensive nature of incontinence in this setting. NH

Urge incontinence

• Most common type in the elderly.
• Symptoms include abrupt urge, frequency, and nocturia.
• Associated with detrusor muscle overactivity.
• Can be age-related or caused by bladder infection or urethral irritation.

Stress incontinence

• Second most common type in older women.
• Results from impaired urethral closure caused by insufficient pelvic support.
• Coincident with increases in intra-abdominal pressure (e.g., coughing, sneezing, laughing, walking stairs, bending, or lifting).

Overflow incontinence

• Results from detrusor muscle underactivity, bladder outlet obstruction, or both.
• Can result from impaired or absent contractility of the bladder (neurogenic bladder). Neurogenic bladder may be caused by neurologic conditions, such as diabetic or other neuropathy, lower spinal cord injury, or pelvic nerve damage from surgery or radiation therapy.
• Involuntary loss of urine is associated with overdistension.
• Symptoms include dribbling, weak urinary stream, hesitancy, frequency, and nocturia.

Functional incontinence

• Occurs in residents who would be continent but cannot reach the toilet facilities in time because of physical or cognitive problems or medication reactions.
• Causes include dementia, confusion, poor eyesight, inflammatory joint disease, poor strength, poor mobility, or poor dexterity.
• Also caused by unwillingness to toilet because of depression, anxiety, anger, or excessive distance to toilet facilities.
• Affected by environmental factors, such as poor lighting, low chairs that are difficult to get out of, and physical restraints.

Transient incontinence

• Temporary episodes that are reversible once the cause is identified and treated.
• Causes include delirium, infection, atrophic urethritis or vaginitis, some pharmaceuticals (e.g., sedatives, hypnotics, diuretics, and anticholinergic agents), excessive urine production, restricted mobility, and fecal impaction.

*Above definitions are derived from the proposed CMS survey protocol.

• What are the specific needs of the facility and the residents?
• Are specific policies and procedures related to the use of the products needed?
• Can the supplier/manufacturer assist the facility with a program or system for managing incontinence?
• Can the supplier/manufacturer provide tools (e.g., assessment forms, tracking forms, risk assessment forms), training manuals, hands-on staff training, and a retraining program?
• Can the supplier/manufacturer provide outcomes statistics?
• How well do this supplier/manufacturer’s products perform?

Keys to effective urinary incontinence management programs in long-term care include:

• Operational focus on specific programs and outcomes, as well as the need for investment in high-quality absorbent products with a variety of applications.
• Evaluation of the true cost of incontinence, especially if poorly managed, to operations.
• Adequate involvement of the attending physician, medical director, and consulting physicians.
• Consistent terminology, documentation processes, and communication of status, using the structure of the MDS definitions and the required assessment process, depending on identification of the type of incontinence and risk factors.
• Well-defined toileting and bladder retraining programs, known and understood by all staff and outcomes-focused.
• Proper policies and procedures for specimen collection and laboratory test requests, as well as action steps when results are reported.
• Ongoing assessment and planning to reinforce resident improvements in continence, and adaptation of interventions when goals are reached or new problems discovered.
• Selection of proper type and size of absorbent product(s) for each resident.
• Ongoing review of the Quality Indicator database and other related data to confirm outcomes, functional performance changes, and regulatory risk issues.
• Careful consideration of the necessity for catheter use and the implementation of current safe policies and procedures for catheter insertion, catheter care, and perineal care.
• Investment in training of all staff related to causes of incontinence, types of incontinence, treatments, medications, need for consultation with other professionals, and the sizing and types of absorbent products and their use.
• Education of residents and families in bladder and bowel retraining or toileting programs, as well as in proper product use and recognition of symptoms of urinary tract infection.

Leah Klusch