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Helping Residents Stay Dry

June 1, 2003
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An interview with MAry H Palmer, PhD
Helping Residents Stay Dry

AN INTERVIEW WITH MARY H. PALMER, PHD Because of physical changes associated with aging and sometimes caused by cognitive decline, many elderly residents in long-term care settings struggle with urinary incontinence, despite efforts by staff to help them remain continent. According to expert Mary H. Palmer, PhD, a professor at the University of North Carolina at Chapel Hill School of Nursing, vital keys to helping elderly residents stay dry are thorough evaluation and individualized care plans. In this interview, Dr. Palmer shares her insights on what long-term care facilities can do to better manage incontinence, how to determine the best toileting schedule, and more.

Are there any recent research findings regarding urinary incontinence that might be of interest to our readers and might help them provide better care?
Dr. Palmer:
Some researchers have combined toileting with a low-intensity exercise program as a method to care for nursing home residents who suffer from incontinence (Schnelle JF, Kapur K, Alessi C, et al. J Am Geriatr Soc 2003;51:161-8). The reasoning is that if caregivers can help residents retain their mobility and function through exercise, thereby enabling them to reach the toilet in time, it might maintain or improve their continence level. The researchers found this approach more effective than a toileting program alone in terms of improving residents' strength, mobility, endurance, and urinary and fecal incontinence. The study sought to show cost savings from this approach. While that outcome was not shown, the researchers concluded that there were clear advantages in terms of quality of life.

If you were establishing an incontinence-management program in a long-term care facility, what components would you consider indispensable?
Dr. Palmer:
First, it is extremely important that there be a true buy-in from the organization's administration. The program has to be valued by upper levels and spread throughout the organization. Many times we expect frontline staff, the CNAs, to take a program and run with it, but then administration neither asks how it's going nor promotes its value. Therefore, the program can lose momentum.

The message should be that incontinence is an important issue in our facility, and that the program and measures put in place to deal with it are important, as well. In fact, more importantly, if you can change the organization's culture so that instead of thinking in terms of incontinence, staff and administration are thinking in terms of continence, the next step will be to ask how you can change the environment to reflect that value. Thinking in those terms might reveal new, effective strategies.

Another component of a successful program is that everyone must understand the program's goals. They must be realistic, so that no one is disappointed by false expectations. Sometimes we can't get residents 100% dry, and sometimes they won't become dry on behavioral interventions alone. Staff need to have input regarding what will and won't work, and family members should be considered part of the care team, too.

What makes for a successful toileting program?
Dr. Palmer:
Toileting schedules have to be individualized, based on resident assessments. Assessment should include factors that cause transient/reversible incontinence (such as urinary tract infection, urinary retention, dehydration, delirium, restricted mobility, atrophic vaginitis, urethritis, fecal impaction, and polypharmacy). A bladder record should be kept to help determine the type and frequency of incontinence. The RAP (Resident Assessment Profile) provides guidance in terms of the baseline evaluation of incontinence in nursing homes.

In addition to this assessment, a physical examination, a detailed assessment of the genitourinary system, functional assessment, and evaluation of environmental barriers (such as changes in living conditions, clothing, location of toilet, and/or nighttime access to toilet) need to be performed.

A toileting schedule of every two hours has been commonly used, but that might not be appropriate for all residents; and given staff-to-resident ratios, that schedule is difficult to maintain. Some residents can, in fact, do quite well on a schedule of every 3 or 4 hours.

Prompted voiding is most successful in the more cognitively intact residents who can recognize their need to void. According to Lyons and Specht (Lyons SS, Specht JK. J Gerontol Nurs 2000;26:5-13), other good indicators that prompted voiding will be successful are that the resident generally voids four or fewer times during the day, appropriately uses the toilet more than 66% of the time during the first three days of prompted voiding, voids in toileting receptacles at least 50% of the time on the first day of prompted voiding, can void successfully when given toileting assistance, can ambulate independently, has a maximum voided volume of more than 1,500 cc, and has a residual after voiding less than 100 cc.

In addition to these behavioral programs, are there any medications for treating incontinence that you consider useful in the nursing home setting?
Dr. Palmer:
There are some pharmacologic treatments for urge incontinence, such as a muscle relaxant for the bladder, but there are none yet for stress incontinence. However, contraindications exist for the use of these agents in the geriatric population. The old adage "start low and go slow" certainly would apply here, but we should keep in mind that not a lot of research with these drugs has been conducted in this population.