Helping Residents Stay Dry
| 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?
If you were establishing an incontinence-management program in a long-term care facility, what components would you consider indispensable?
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?
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?
For residents who have been diagnosed with urge incontinence and who can tolerate medications with anticholinergic effects, there are medications that may be helpful, such as tolterodine and oxy-butynin. These drugs can cause dry mouth, blurred vision, constipation, and mental status changes, however. A tricyclic antidepressant, imipramine, has also been used for urge incontinence. It can cause postural hypotension, cardiac arrhythmia, weakness, and fatigue. Both oxybutynin and imipramine can increase intraocular pressure. Because of these drugs’ associated side effects, careful review of the person’s medical history, assessment of baseline function prior to administering medication, and monitoring of the person’s reaction to medication are essential.
In your view, what are the most common mistakes long-term care facilities make in their programs to manage urinary incontinence?
A mistake that some residents make-and we should watch for this-is to stop drinking fluids in an attempt to avoid accidents. Just the opposite result can occur; without enough fluid, the bladder can become irritated, and low-volume voiding can occur.
Are there any specific evaluation tools or methods for assessing residents with urinary incontinence that you consider particularly useful?
What do you consider to be the most successful measures to help residents overcome urinary incontinence?
What are some other methods to help residents remain continent?
You should also monitor bowel function, because minimizing constipation can also help bladder function. Also, older women should be checked for atrophic vaginitis-and treated if they have it. For women who do not have a medical history that would contraindicate estrogen use, low-dose topical estrogen cream for a short-term course may be helpful in alleviating atrophic vaginitis. This can improve urge incontinence in some women.
Another useful tool for caregivers is the new supplement to the American Journal of Nursing that came out in March, on the state of the science on urinary incontinence. The supplement, which includes an article on incontinence in the frail elderly and will be especially useful for long-term care nurses, is available free online. It can be downloaded from NursingCenter.com/UI. Also, 6.5 CE credits are available in association with the supplement. NH
|Mary H. Palmer, PhD, is the Helen Watkins and Thomas Leonard Umphlet distinguished professor in aging at the University of North Carolina at Chapel Hill School of Nursing. She has 20 years’ research in the management of urinary incontinence in older populations and has written several papers on the subject. To comment on this article, please send e-mail to firstname.lastname@example.org.|
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