Correct assessment is key to treatment

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;

• Type of UI the resident is experiencing: Urge Incontinence (overactive bladder)—UI characterized by abrupt urgency, frequency, and nocturia; resident has incontinence episodes before getting to the bathroom; resident asks to wear pads to prevent the embarrassment of “leaking.” Stress Incontinence—present in women with relaxation of the periurethral musculature; exacerbated in women who have experienced childbirth; present in men who have undergone prostate surgery; leakage occurs in response to increased abdominal pressure; incontinence occurs with coughing, sneezing, laughing, or exercise. Mixed Incontinence—combination of stress and urge incontinence. Overflow Incontinence—caused by a mechanical or functional obstruction of the bladder outlet (often by an enlarged prostate), leads to weak urine stream and frequent dribbling, is associated with leakage of small amounts of urine when the bladder has reached its maximum capacity and has become distended. Functional Incontinence—UI that is secondary to factors other than inherently abnormal urinary tract function; may be related to physical weakness, poor mobility, confusion, or dementia. Transient Incontinence—temporary or occasional UI episodes that are reversible once the cause(s) is identified; possible causes may include increased urine production, restricted mobility, infection, and medication.

While the collection and consideration of all of these factors in the evaluation of UI takes time and diligence on the part of the interdisciplinary team, once an initial assessment has been completed, subsequent assessments can primarily focus on changes in the resident’s condition or a targeted review of pertinent items. An understanding of the purpose behind the comprehensive assessment is critical to the analysis of information. The purpose being to determine the cause(s) of the incontinence, to identify and remove contributing factors, and to restore bladder function/manage the incontinence to the extent possible depending upon the individual resident’s needs. Staff must understand that UI is not an inevitable part of aging and know the signs and symptoms commensurate with specific types of UI and corresponding treatment modalities. In addition, a facility must have a system in place that captures subtle declines in the level of UI a resident is experiencing so that an assessment can be completed as soon as possible in the hopes of restoring bladder function to the prior level.

Jan Bennet, RN, NHA, is the Executive Vice-President of the American Association of Nurse Executives (AANEX).

For more information, phone (877) 457-7208 or visit https://www.aanex.com. To send your comments to the author and editors, e-mail bennet0408@iadvanceseniorcare.com

References

1. Guidance to Surveyors for Long‐Term Care Facilities. Centers for Medicare & Medicaid State Operations Manual, Appendix PP. Retrieved January 28, 2008, from www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
2. Lekan‐Rutledge D, Colling J. Urinary incontinence in the frail elderly. American Journal of Nursing 2003; 103 ( 3 ): 36–46.
3. Clinical practice guideline: Urinary incontinence. American Medical Directors Association. Columbia MD; 2006.

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