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Correct assessment is key to treatment

April 1, 2008
by Jan Bennet, RN, NHA
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Don't discount underlying, contributing factors in UI

Aggregate MDS data indicates that more than 50% of the nursing home population experiences some degree of urinary incontinence (UI).1 UI, however, is not a normal, inevitable consequence of aging. Its prognosis depends on the cause and severity of symptoms and not on the age of the individual. Assessment of underlying, contributing factors and identification of the type of UI are keys to successful treatment. Targeted interventions can sometimes lead to improvement in bladder control and a decrease in the frequency of incontinence. Even if underlying conditions are irreversible, an individualized, resident-directed approach can help to prevent complications and improve a resident's quality of life.

The first step to providing appropriate care and treatment is to complete an accurate, thorough assessment. According to the Nursing Home Federal Requirements and Guidelines to Surveyors, CFR 483.25(d)(2), F315, a resident should be assessed for UI at the time of admission and whenever there is a change in cognition, physical ability, or urinary tract function.1 It is not uncommon, however, for a resident to decline from occasionally or frequently incontinent to totally incontinent without staff recognizing the need for assessment and aggressive intervention. Additionally, comprehensive assessments sometimes do not include a thorough review of all pertinent information due to time constraints and a propensity to manage rather than reverse the incontinence. This is especially true in the case of residents who are cognitively impaired. In the frail elderly, UI is usually the result of disequilibrium in multiple body systems, functional impairments, and drugs and therefore a comprehensive assessment is important.2

The federal requirements specify that the following information be considered when completing a comprehensive assessment for UI:1

  • Prior history of UI (including onset, duration, and characteristics), precipitants of UI, associated symptoms (e.g., dysuria, polyuria, hesitancy), and previous treatment and/or management

  • Voiding patterns such as frequency, volume, nighttime or daytime, quality of stream, and for those already experiencing urinary incontinence, voiding patterns over several days

  • Medication review, looking particularly at those that might affect continence: (1) Medications with anticholinergic properties that may cause urinary retention and possible overflow incontinence; (2) Sedative/hypnotics that may cause sedation leading to functional incontinence; (3) Diuretics that may cause urgency, frequency, or overflow incontinence; (4) Narcotics; (5) Alpha-adrenergic agonists that may cause urinary retention in men; (6) Antagonists that may cause stress incontinence in women; (7) Calcium channel blockers that may cause urinary retention

  • Patterns of fluid intake to include amounts, time of day, alterations, and potential complications such as decreased or increased urine output

  • Use of urinary tract stimulants or irritants (e.g., frequent caffeine intake)

  • Pelvic and rectal examination to identify physical features that may directly affect urinary incontinence: prolapsed uterus or bladder, prostate enlargement, significant constipation or fecal impaction, use of a urinary catheter, atrophic vaginitis, distended bladder, bladder spasms

  • Functional and cognitive capabilities that could enhance urinary continence as well as limitations that could adversely affect continence: impaired cognitive function or dementia, impaired immobility, decreased manual dexterity, the need for task segmentation, decreased upper and lower extremity muscle strength, decreased vision, pain with movement

  • Type and frequency of physical assistance necessary to assist the resident to access the toilet, commode, urinal, and the types of prompting needed to encourage urination

  • Pertinent diagnoses or medical conditions that may contribute to incontinence, such as congestive heart failure, stroke, diabetes mellitus, obesity, neurological disorders (e.g., multiple sclerosis, Parkinson's disease or tumors that could affect the urinary tract or its function), urinary tract infections, edema, cognitive impairment, fecal impaction, or severe diarrhea, tumors or fistulas, anxiety, depression, or decreased muscle tone

  • Identification of and/or potential for developing complications such as skin irritation or breakdown

  • Tests or studies indicated to identify the type(s) of urinary incontinence: post-void residual(s) for residents who have, or are at risk for, urinary retention; results of any urine culture if the resident has clinically significant systemic or urinary symptoms; evaluations assessing the resident's readiness for bladder rehabilitation programs

  • Environmental factors and assistive devices that may restrict or facilitate a resident's ability to access the toilet, such as grab bars, raised or low toilet seats, inadequate lighting, distance to the toilet or bedside commode, availability of urinals, use of bed rails or restraints, or fear of falling and;