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Enhanced continence care

March 1, 2009
by Anne Earthy, BN, MA GNC(C) and Avinoam Nativ, PhD, PT
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In Canada, innovative approaches to improve mobility offer the advantages of routine toileting

Resident incontinence represents a major challenge for the long-term care (LTC) industry. It negatively impacts residents on many levels and has a significant economic impact on the service provider both in terms of the support care required and direct-expense costs. The Canadian Continence Foundation has estimated that the cost of a senior with incontinence living in a Canadian LTC facility can average $3,000 to $10,000 per year for supplies and related nursing care.

Urinary incontinence (UI) is defined as the complaint of any involuntary leakage of urine. In LTC facilities, more than 50% of persons experience UI either occasionally or on a regular basis and many would argue the rate is even higher. UI is a contributing factor to skin breakdown, falls, urinary tract infections, social isolation, frustration, anxiety, calling out, and wandering.

Recent research by Earthy into the advantages of routine toileting has shown that maintaining a “normal” toileting pattern, in a sitting position and in a private space, contributes to improved resident self-esteem and dignity. Determining resident voiding and bowel patterns and having staff assist them to the bathroom according to each resident's natural schedule is sometimes seen by staff as too time-consuming. However, a time analysis performed by an independent body to compare the time it took to cleanse residents on the control unit to caring for the residents on the research unit who were assisted to the bathroom (with or without mechanical devices) suggested that it took only 2.01 minutes longer to toilet a person and return him or her to a chair or bed than it did to cleanse the person in bed. In addition, there were financial savings of over $30,000 annually for the 75-bed unit related to decreased use of linens, briefs, and medications. With a focused approach that included interdisciplinary staff and residents' education, bladder scanning, and encouragement of a “normal” toileting pattern, the study showed that, in just one year, the percentage of residents toileted regularly to void rose from 12% to 67% in the research group. This is a remarkable difference that resulted in statistically significant gains in appetite, sleep, self-care, and in decreased calling out and wandering.

A United Kingdom paper, Health Care of Older People Program (2005), concluded that there is a missed opportunity to assess, treat, and reduce the number of persons experiencing incontinence, because there tends to be more emphasis on containment rather than cure. This is expensive, from both a financial and health perspective. Instead, more attention needs to be directed to promoting and maintaining continence abilities and preventing avoidable bowel and urinary continence decline. Staff education is required to disseminate research findings that demonstrate that incontinence is not a normal part of aging and that continence can often be maintained when the team works together to maintain residents' lifelong elimination patterns.

Encouraging normal voiding patterns is clearly essential for improved continence, but there are other ways a facility can help encourage more residents to maintain and even regain the ability to self-toilet. Treatment of functional incontinence depends on the successful management of causative or contributing conditions. Several key physical factors including mobility, transfer ability, strength, and flexibility are essential for independent toileting. Targeting these abilities for improvement, then, is crucial in any effort to increase the number of individuals who can self-toilet.

Innovative mobility training tools provide LTC facilities with the capacity to effectively improve residents' ability to sit, stand, transfer, and walk. A key by-product of improved standing and mobility is the ability to manage toileting more independently. One such device (figure 1) is designed to help residents who cannot stand regain the ability to stand independently. Actively assisting the standing motion with support at the knee, trunk, and arms to promote early mobility, the Sit-to-Stand Trainer uses a counterweight mechanism to provide a safe and effective way to strengthen weight-bearing muscles and increase standing stability and endurance. Unlike other tools that lift people to or maintain them in a standing position, this equipment enables a resident to successfully initiate the motion of standing up, even with weakened or seemingly unsuccessful efforts. Through regular training (typically a few minutes 3 to 4 times per week) and gradually reducing the counterweight, a resident can relearn the standing up skill and redevelop the strength and confidence necessary to do so more independently.

For residents who are able to stand but lack the strength, balance, and confidence to walk, a body-weight bungee support tool enables motor retraining (figure 2). It provides safe ways to practice balance, walking, and natural protective side-steps, by counteracting loss of stability with graduated support from beneath. This allows residents to safely begin to walk and work on balance skills without being held up by an overhead harness that doesn't allow natural responses, and hence useful practice, in loss-of-balance situations.