Pad per day usage, urinary incontinence and urinary tract infections in nursing home residents

Benefits of a digital health technology for older nursing home residents. A de-novo cost-effectiveness model for digital health technologies to aid in the assessment of toileting and containment care needs

The aim of this study was first, to introduce a comprehensive, de-novo health economic (HE) model incorporating the full range of activities involved in toileting and containment care (T&CC) for people with incontinence, capturing all the potential benefits and costs of existing and future Digital Health Technologies (DHT) aimed at improving continence care, for both residential care and home care. Second, to use this novel model to evaluate the cost-effectiveness of the DHT TENA SmartCare Identifi in the implementation of person-centred continence care (PCCC), compared with conventional continence care for Canadian nursing home residents. The de-novo HE model was designed to evaluate technologies across different care settings from the perspective of several stakeholders. Health states were based on six care need profiles with increasing need for toileting assistance, three care stages with varying degrees of toileting success, and five levels of skin health. The main outcomes were incremental costs and quality-adjusted life years. The effectiveness of the TENA SmartCare Identifi was based primarily on trial data combined with literature and expert opinion where necessary. Costs were reported in CAD 2020. After 2 years, 21% of residents in the DHT group received mainly toileting as their continence care strategy compared with 12% in the conventional care group. Conversely, with the DHT 15% of residents rely mainly on absorbent products for incontinence care, compared with 40% with conventional care. On average, residents lived for 2.34 years, during which the DHT resulted in a small gain in quality-adjusted life years of 0.015 and overall cost-savings of $1,467 per resident compared with conventional care. Most cost-savings were achieved through reduced costs for absorbent products. Since most, if not all, stakeholders gain from use of the DHT-assisted PCCC, widespread use in Canadian residential care facilities should be considered, and similar assessments for other countries encouraged.

Cost consequence analysis of transcutaneous tibial nerve stimulation (TTNS) for urinary incontinence in care home residents alongside a randomised controlled trial

BACKGROUND

Urinary incontinence (UI) is prevalent in more than half of residents of nursing and residential care homes and can have a detrimental impact on dignity and quality of life. Care homes predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive, safe, low-cost intervention with demonstrated effectiveness for reducing UI in adults. We examined the costs and consequences of delivering TTNS to care home residents in comparison to sham (inactive) electrical stimulation.

METHODS

A cost consequence analysis approach was used to assemble and present the resource use and outcome data for the ELECTRIC trial which randomised 406 residents with UI from 37 care homes in the United Kingdom to receive 12 sessions of 30 min of either TTNS or sham (inactive) TTNS. TTNS was administered by care home staff over 6 weeks. Health state utility was measured using DEMQOL-U and DEMQOL-PROXY-U at baseline, 6 weeks and 18 weeks follow-up. Staff completed a resource use questionnaire at baseline, 6 weeks and 18 weeks follow-up, which also assessed use of absorbent pads.

RESULTS

HRQoL did not change significantly in either randomised group. Delivery of TTNS was estimated to cost £81.20 per participant, plus training and support costs of £121.03 per staff member. 85% of participants needed toilet assistance as routine, on average requiring one or two staff members to be involved 4 or 5 times in each 24 h. Daily use of mobility aids and other assistive devices to use the toilet were reported. The value of staff time to assist residents to use the toilet (assuming an average of 5 min per resident per visit) was estimated as £19.17 (SD 13.22) for TTNS and £17.30 (SD 13.33) for sham (per resident in a 24-hour period).

CONCLUSIONS

Use of TTNS to treat UI in care home residents did not lead to changes in resource use, particularly any reduction in the use of absorbent pads and no cost benefits for TTNS were shown. Managing continence in care homes is labour intensive, requiring both high levels of staff time and use of equipment aids.

TRIAL REGISTRATION

ISRCTN98415244, registered 25/04/2018. NCT03248362 (Clinical trial.gov number), registered 14/08//2017.

Urinary and Double Incontinence in Cognitively Impaired Patients: Impacts on Those Affected and Their Professional Caregivers

Urinary or double incontinence in frail elderly people is common and leads to a reduction in quality of life and an increased burden on the patients' caregivers. Up to now, no special instrument has been available to assess the impact of incontinence on cognitively impaired patients and their professional caregivers. Thus, the outcomes of incontinence-specific medical and nursing interventions for cognitively impaired individuals are not measurable. Our aim was to investigate the impacts of urinary and double incontinence on both the affected patients and their caregivers using the newly developed "International Consultation on Incontinence Questionnaire Cognitively Impaired Elderly" (ICIQ-Cog) tool. The severity of incontinence was measured by incontinence episodes per night/per 24 h, the type of incontinence, the type of incontinence devices used, and the proportion of incontinence care out of total care; all these measures were correlated to the ICIQ-Cog. Incontinence episodes per night and the proportion of incontinence care out of total care showed significant correlations with the patient- and caregiver-related ICIQ-Cog scores. Both items have negative effects on patient quality of life and caregiver burden. Improving nocturnal incontinence and reducing the need for incontinence care overall can decrease the incontinence-specific bother of affected patients and their professional caregivers. The ICIQ-Cog can be used to verify the impacts of medical and nursing interventions.

A post-market cluster randomized controlled trial of the effect of the TENA SmartCare Change Indicator™ on urinary continence care efficiency and skin health in older nursing home residents

BACKGROUND

Urinary continence care for residents of nursing homes who are unable to communicate their toileting needs usually involves care aides manually checking continence products (pads) to determine the level of urine saturation prior to changing. The TENA SmartCare Change Indicator is a medical device which estimates urine saturation and notifies caregivers of the optimal time for pad changes. This study will seek to examine the effect of the TENA SmartCare Change Indicator on urinary continence care efficiency and skin health, in comparison to usual care.

METHODS

This cluster randomized controlled trial (NCT05247047) involving older nursing home residents with urinary incontinence unable to consistently indicate their toileting needs, and their care aides, will compare technology-based and usual continence care over a period of 8 weeks. Co-primary endpoints of superiority in continence care efficiency and non-inferiority in the maintenance of skin health will be assessed. Secondary outcomes will examine the resident quality of life, sleep quality, responsive behaviours, changes in pad use and leakage episodes outside the pad. Change in care aide work engagement, job satisfaction and rushed tasks will be assessed. Benefits and challenges with the use of the device for continence care will be identified from the perspectives of the care staff.

DISCUSSION

Urinary continence assessment and care in nursing homes is reported as suboptimal and threatening to dignity. Data on the utility and effect of technological solutions for improving urinary continence care are few and conflicting. If shown effective, this technological solution has the potential to improve the care for older residents and improve the working lives of caregiving staff who look after this most vulnerable section of the population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05247047. Registration date is Feb 18, 2022.

Association between pre-stroke sarcopenia risk and stroke-associated infection in older people with acute ischemic stroke

Background

Stroke-associated infection (SAI) is a common complication after a stroke. The incidence of infection was higher in people with sarcopenia than in the general population. However, the relationship between pre-stroke sarcopenia risk and SAI in older patients has not been confirmed. This study aimed to investigate the association between pre-stroke sarcopenia risk and SAI in older patients with acute ischemic stroke (AIS).

Methods

This retrospective study was conducted by the Peking University People's Hospital. We evaluated the pre-stroke sarcopenia risk by applying the SARC-F questionnaire. Multivariate logistic regression was applied to explore the association between pre-stroke sarcopenia risk and SAI.

Results

A total of 1,002 elder patients with AIS (592 men; 72.9 ± 8.6 years) were enrolled in our study. Pre-stroke sarcopenia risk was found in 29.1% of the cohort. The proportion of patients with pre-stroke sarcopenia risk was larger in the SAI group than in the non-SAI group (43.2 vs. 25.3%, p   < 0.001). In multivariate logistic analysis, pre-stroke sarcopenia risk was shown to be independently associated with SAI (OR = 1.454, 95% CI: 1.008-2.097, p = 0.045) after adjusting for potential factors. This association remained consistent across the subgroups based on age, sex, body mass index, smoking status, drinking status, diabetes, hypertension, and dyslipidemia.

Conclusion

Pre-stroke sarcopenia risk was independently associated with SAI in older patients with AIS. Our findings highlight the significance of pre-stroke sarcopenia identification in the prevention and management of SAI in this population.

Adult incontinence products are a larger and faster growing waste issue than disposable infant nappies (diapers) in Australia

The environmental issues relating to disposable of infant nappies have received considerable attention. However, adult absorbent hygiene products (AHPs) receive less attention, despite having comparable or greater environmental impact. Here we quantify and compare current and future flows of continence related AHPs entering waste streams from both infant and adult populations. Importantly our study accounts for current waste management and landfilling practices across Australia and the environmental implications of AHP disposal. Absorbent hygiene product use from infants and adults was modelled from 2020 to 2030 for Australia, and it's predicted that AHP waste generated by adults will account for between 4 and 10 times that of infants by 2030 due to an aging population. Our results indicate that 50% of used AHPs end up in landfill with both leachate and biogas collection, the remainder going to landfills without biogas collection or without both leachate and biogas collection, based on the most recent national data set, which is over a decade old. The average composition of used absorbent hygiene product (including 60% urine and faeces by mass) is estimated to contain 20% non-biodegradable material, which may complicate the biodegradability of absorbent hygiene products in landfill. Without additional regulatory incentive, the current waste management practices in Australia are likely to continue, with absorbent hygiene products typically entering landfill as municipal solid waste, rather than industrial composting or recycling facilities. More accurate estimation of environmental implications from these disposal pathways requires further work including biodegradation experiments currently unavailable in the literature.

Factors associated with urinary tract infection in a Nursing Home

OBJECTIVE

to analyze the factors associated with urinary tract infection occurrence in institutionalized elderly.

METHODS

this is a cross-sectional, analytical, quantitative study with 116 elderly people from a Nursing Home. Urinary tract infection diagnosis was carried out through urine culture and clinical assessment. Demographic data and associated factors were obtained from medical records. Statistical analysis included bivariate analysis and logistic regression models.

RESULTS

the factors associated with urinary tract infection (p<0.05) were being female; wheelchair user; diaper use; diuretic use; urinary and bowel incontinence; type 1 diabetes; benign prostatic hyperplasia; dehydration.

CONCLUSION

this study revealed that it is important to consider non-modifiable factors such as sex and clinical comorbidities; however, dehydration, a modifiable factor, increased the chances of developing urinary tract infections by 40 times among institutionalized elderly and demands greater attention from the health team.

Tibial nerve stimulation compared with sham to reduce incontinence in care home residents: ELECTRIC RCT

BACKGROUND

Urinary incontinence is prevalent in nursing and residential care homes, and has a profound impact on residents' dignity and quality of life. Treatment options are limited in these care contexts and care homes predominantly use absorbent pads to contain incontinence, rather than actively treat it. Transcutaneous posterior tibial nerve stimulation is a non-invasive, safe, low-cost intervention that is effective in reducing urinary incontinence in adults.

OBJECTIVE

To determine the clinical effectiveness of transcutaneous posterior tibial nerve stimulation to treat urinary incontinence in care home residents and to determine the associated costs of the treatment.

DESIGN

A multicentre, pragmatic, participant and outcome assessor-blind, randomised placebo-controlled trial.

SETTING

A total of 37 UK residential and nursing care homes.

PARTICIPANTS

Care home residents with at least weekly urinary incontinence that is contained using absorbent pads and who are able to use a toilet/toilet aid with or without assistance.

INTERVENTIONS

Residents were randomised (1 : 1) to receive 12 30-minute sessions of transcutaneous posterior tibial nerve stimulation or sham stimulation over a 6-week period.

MAIN OUTCOME MEASURES

Primary outcome - change in volume of urine leaked over a 24-hour period at 6 weeks. Secondary outcomes - number of pads used, Perception of Bladder Condition, toileting skills, quality of life and resource use.

RESULTS

A total of 408 residents were randomised (transcutaneous posterior tibial nerve stimulation, n = 197; sham stimulation, n = 209); two exclusions occurred post randomisation. Primary outcome data were available for 345 (85%) residents (transcutaneous posterior tibial nerve stimulation, n = 167; sham stimulation, n = 178). Adherence to the intervention protocol was as follows: 78% of the transcutaneous posterior tibial nerve stimulation group and 71% of the sham group received the correct stimulation. Primary intention-to-treat adjusted analysis indicated a mean change of -5 ml (standard deviation 362 ml) urine leakage from baseline in the transcutaneous posterior tibial nerve stimulation group and -66 ml (standard deviation 394 ml) urine leakage in the sham group, which was a statistically significant, but not clinically important, between-group difference of 68-ml urine leakage (95% confidence interval 0 to 136 ml; p = 0.05) in favour of the sham group. Sensitivity analysis supported the primary analysis. No meaningful differences were detected in any of the secondary outcomes. No serious adverse events related to transcutaneous posterior tibial nerve stimulation were reported. Economic evaluation assessed the resources used. The training and support costs for the staff to deliver the intervention were estimated at £121.03 per staff member. Estimated costs for delivery of transcutaneous posterior tibial nerve stimulation during the trial were £81.20 per participant. No significant difference was found between participants' scores over time, or between transcutaneous posterior tibial nerve stimulation and sham groups at any time point, for resident or proxy quality-of-life measures.

CONCLUSIONS

The ELECTRIC (ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes) trial showed, in the care home context (with a high proportion of residents with poor cognitive capacity and limited independent mobility), that transcutaneous posterior tibial nerve stimulation was not effective in reducing urinary incontinence. No economic case for transcutaneous posterior tibial nerve stimulation was made by the cost-consequences analysis; however, the positive reception of learning about urinary incontinence for care home staff supports a case for routine education in this care context.

LIMITATIONS

Completing 24-hour pad collections was challenging for care home staff, resulting in some missing primary outcome data.

FUTURE WORK

Research should investigate transcutaneous posterior tibial nerve stimulation in residents with urgency urinary incontinence to determine whether or not targeted stimulation is effective. Research should evaluate the effects of continence training for staff on continence care in care homes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98415244 and ClinicalTrials.gov NCT03248362.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 41. See the NIHR Journals Library website for further project information.

Prevalence and predictors of continence containment products and catheter use in an acute hospital: A cross-sectional study

Although incontinence is common in hospital, the prevalence and predictors of continence aid use (continence wear and catheters) are poorly described. A one-day cross-sectional study was conducted in a large university hospital assessing consecutive inpatients (≥55) for their pre-admission and current use of continence aids. Barthel Index, Clinical Frailty Scale and Charlson Co-morbidity scores were recorded. Appropriateness was defined by local guidelines. 355 inpatients, median age 75±17 years, were included; 53% were male. Continence aid use was high; prevalence was 46% increasing to 58% for those ≥75. All-in-one pads were the most common, an overall prevalence of 31%. Older age, lower Barthel and higher frailty scores were associated with continence aid use in multivariate analysis. Inappropriate use of aids was high at 45% with older age being the only independent predictor. Continence aids are often used inappropriately during hospitalisation by older patients. Concerted efforts are required to address this issue.

Care dependency and management of urinary incontinence in nursing homes: A descriptive study

AIM

To explore the differences in managing urinary incontinence in residents in nursing homes aged 65 years or older in relation to their care dependency.

DESIGN

The 2015 data of the Dutch annual independent (Inter)national Prevalence Measurement of Quality of Care of Maastricht University were used. The design involved a cross-sectional, multi-centre point prevalence measurement in hospitals, care homes, and home care.

METHODS

Secondary data analysis on the data provided by care home organizations.

RESULTS

In the care independent group, the solely use of absorbing material was the mostly applied intervention. In the group of care dependent persons, the combination of absorbing material with toilet on set times and on individual basis was the most common approach.

CONCLUSION

The outcome of this study indicated that the management of urinary incontinence in residents in nursing homes differs depending on their care dependency.

IMPACT

Caregivers in nursing homes should be aware of preferences of residents regarding the management of their urinary incontinence. Researchers should investigate criteria used by caregivers and care receivers into the decision of the application of interventions for urinary incontinence.

Development of a Toileting and Containment Decision Support Tool

A multidisciplinary international expert panel was convened to provide input for a proposed decision support tool. This tool will assist health care professionals who are not specialized in incontinence care to assess individuals with urinary and/or fecal incontinence and recommend appropriate person-centered management options for the home care and ambulatory community settings. A targeted literature review was complemented by a series of interviews with experts in continence management, followed by a practitioner survey and rounds of expert opinion. A set of factors for assessment were defined, along with questions created to identify and quantify the factors. In addition, a range of lifestyle intervention, toileting and containment strategies were identified that were appropriate for the decision support tool. Future steps required to progress this work to a functioning tool are described.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Current controversies in urinary tract infections: ICI-RS 2017

AIMS

The current definition of urinary tract infection (UTI) relies on laboratory and clinical findings, which may or may not be relevant, depending upon the patient group under consideration. This report considers the utility of current definitions for UTI in adults with and without underlying neurological conditions in order to identify gaps in current understanding and to recommend directions for research.

METHODS

This is a consensus report of the proceedings of Think Tank TT3: "How do we define and when do we treat UTI in neurological and non-neurological adult patients?" from the annual International Consultation on Incontinence-Research Society (ICI-RS), June 8-10, 2017 (Bristol, UK).

RESULTS

Evidence considering the definitions of UTI in patients with and without neurological diseases was reviewed and synthesized. We examined research on laboratory methods and clinical definitions, focusing on specific cut-off values for the quantification of significant bacteriuria, and leucocyturia. Several areas were identified, mostly related to the lack of evidence-based definitions of significant bacteriuria for different patient groups, as well as uncertainties about the role of inflammatory biomarkers, and non-specific symptoms and signs.

CONCLUSIONS

One of the biggest challenges in clinical practice is to discriminate between asymptomatic bacteriuria and symptomatic UTI. Future research should concentrate on risk factors for developing symptomatic UTI in different patient groups. Targeted investigations for specific populations, such as the frail elderly, and patients with neurogenic bladder dysfunction, are still needed.

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.

Evaluating a hydration intervention (DRInK Up) to prevent urinary tract infection in care home residents: A mixed methods exploratory study

OBJECTIVES

To investigate potential effects and acceptability of a theoretically driven hydration intervention (DRInK-Up), on the prevalence of urinary tract infections (UTIs), falls and emergency admissions in care home residents.

METHODS

A single group pre-post evaluation design to test the DRInK-Up intervention, to increase fluid intake by 200-400ml daily. The number of UTIs, falls and emergency hospital admissions for each resident recorded over the DRInK-Up intervention period were compared to rates in the 24 weeks prior. A qualitative investigation of experiences of DRInK-Up was undertaken using focus group interviews with care home staff to determine acceptability.

RESULTS

24 care home residents took part in the intervention. There was a clinically meaningful, but non-statistically significant reduction in number of treated UTIs during the intervention period from 51 UTIs pre-DRInK-Up to 37 post-DRInK-Up (t= .498, 18df, p=0.625). The volume of fluid intake recorded was not correlated with number of UTIs (r= 0.103, p=.676). Falls reported dropped from 52 pre- to 28 post-intervention (t=3.148, df 19, p=0.005). Emergency admissions did not change. Focus group interviews suggested goal setting was uncommon and took the form of externally generated targets for fluid intake rather than negotiated goals. Barriers to increasing fluid intake included resident-related factors or arose from the care home context. A range of facilitators included verbal persuasion, praise and reward.

CONCLUSION

The DRInK-Up study provides preliminary evidence suggesting that increasing daily fluid intake by small amounts may have a potentially positive effect on number of UTIs experienced and number of falls in frail older care home residents. Further research is needed.

[Absorbent products for urinary incontinence management]

INTRODUCTION

Despite therapeutic strategies of female and male urinary incontinence (UI) are currently well defined, there is no precise indication of the real place or strategy use of absorbent products regardless of the etiology of the incontinence or the clinical context.

METHODS

We performed a research from the PubMed database using the following keywords: (urinary incontinence [MESH Terms]) AND absorbent pad [MeSH Terms]; allowing us to isolate 362 articles.

RESULTS

Many protections designs are available over-the-counter without prescription and without reimbursement in France. For "light UI", disposable insert pads are the design that seems to be the most suitable for women, compared to disposable menstrual pads, OR=0.27 [0.14, 0.52], washable pants with integral pad OR=0.12 [0.06, 0.26] or washable insert pads OR=0.05 [0.02, 0.26]. For moderate to severe UI, there is no "best universal product". There are differences between the gender and the use of a panel of protections seems the most appropriate. Both women and men prefer pull-ups to disposable insert pads, OR=0.41 [0.20, 0.87] and OR=0.39 [0.22, 0.68] respectively. In men, a preference in 70 % of subjects for urisheats is observed compared to the protections they usually use (P=0.02). The use of protections improves independence in daily OR activities=0.102 [0.046, 0.158] and quality of life related to UI OR=4.40 [1.74, 7.07] compared to patients not using protections. Despite this, their use must remain cautious because of the potential infectious urinary complications, more frequent in particular in institutional people, with 41 % of users developing at least one urinary infection over an evaluation period of 12 months vs. 11 % of non-users (P=0.001), or immuno-allergic with the "dermatitis associated incontinence" whose prevalence can reach a rate of 50 %.

CONCLUSION

Comparative analyzes of risk-benefit, economic costs, patient satisfaction, protections vs. other measures are lacking. It is necessary to continue the development of these products and to compare more precisely their intrinsic characteristics, to best support patients choices.

Patient pad count is a poor measure of urinary incontinence compared with 48-h pad test: results of a large-scale multicentre study

OBJECTIVE

To determine in a large population of community-dwelling incontinent patients the accuracy and determinants of pad count as a measure of urinary incontinence (UI), using data from a multicentre 48-h pad test study.

MATERIALS AND METHODS

Incontinent patients, who were provided with absorbent products for the period January 2012 to March 2016, volunteered to perform a 48-h home-based pad test and to fill in a diary with information on pad usage. Correlations between UI measures (48-h pad count and pad weight gain, mean pad weight gain per pad) were calculated. Logistic regression analyses were conducted to investigate patient-related and pad usage-related factors influencing pad count.

RESULTS

A total of 14 493 patients (median age 81 years) were included, with a total of 98 362 continence products used overall during the study period. The 48-h pad count showed a weak correlation with 48-h pad weight gain (R² = 0.12; 0.19 for men and 0.11 for women) and mean pad weight gain per pad (R² = -0.03). The weakest correlation was observed among patients using >6 pads/48 h (R² = 0.02). A statistically significant negative association between pad absorption capacity and pad count was observed. Patients using products with a shaped and rectangular design had 34% and 40% higher propensity to use more pads than those using briefs (P < 0.001), respectively.

CONCLUSIONS

The results of this very large observational study confirmed that pad count is a poor measure of UI severity. Pad count only measured 12% of the variability of UI volume and was affected by several patient-related and pad usage-related factors. Consequently, pad count should not be used instead of the pad test as an objective measure of UI when an accurate evaluation is required for research or clinical purposes.

Prevalence of healthcare-associated infections in Dutch nursing homes: follow-up 2010-2017

Following the first point-prevalence study in Dutch nursing homes conducted each November from 2007 to 2009, we conducted a follow-up point-prevalence study of healthcare-associated infections (HCAIs) each November from 2010 to 2017. Similar methods and criteria were used. Resident characteristics were recorded, data collection was performed by the attending elderly care physicians via an online survey, as well as via a specifically designed App from 2012. As of the same year, information on incontinence was added. Between 2010 until 2017 on average 1786 residents per year were included, ranging from 1571 to 2185. HCAI prevalence with respect to age (mean: 83 years) and sex (31% men and 69% women) were similar over all the years. The overall mean prevalence rate in the first four years was 6.7% versus 2.2% in the last six years. Urinary tract infection was the most prevalent HCAI (1.5%). Most HCAIs occurred among residents of rehabilitation units. The prevalence of HCAI varied by nursing home (0.0-37.0%). The average use of antibiotics was stable over the years (6.0%) irrespective of HCAI rate. Use of incontinence materials was on average 73.5% with 64.3% of residents being reported as incontinent. Those implementing improvement of infection control and surveillance within a new setting do need to continue for multiple years before seeing the success of their endeavour.

"Dignity": A central construct in nursing home staff understandings of quality continence care

AIMS AND OBJECTIVES

To explore nursing home staff members' beliefs and expectations about what constitutes "quality continence care" for people living in nursing homes.

BACKGROUND

Most nursing home residents require assistance to maintain continence or manage incontinence. Best practice guidelines promote active investigation of incontinence, treatment of underlying potentially reversible causes, and initial conservative interventions to prevent, minimise and/or treat incontinence. Despite research showing the positive benefits of implementing active interventions, translating the findings of research into practice in nursing homes has been modest. Understanding the perspectives of individuals who provide continence care may help bridge the gap between evidence and practice.

DESIGN

A qualitative exploratory descriptive design.

METHODS

Qualitative interviews were conducted with 19 nursing home staff: eight registered nurses, four enrolled nurses and seven personal care workers working in a nursing home in Australia between 2014-2015. Data were analysed inductively to identify themes and subthemes that described and explained staff beliefs about quality continence care in nursing homes.

FINDINGS

Participants' understanding and expectations about quality continence care were linked to beliefs about incontinence being an intractable and undignified condition in nursing homes. The key theme to emerge was "protecting residents' dignity" which was supported by the following six subthemes: (i) using pads, ii) providing privacy, (iii) knowing how to "manage" incontinence, (iv) providing timely continence care, (v) considering residents' continence care preferences and (vi) communicating sensitively.

CONCLUSION

The findings provide new insight into the basis for continence care practices in nursing homes. Education about continence care should challenge beliefs that limit continence care practice to cleaning, containing and concealing incontinence. There is a need for a multidimensional framework that is informed by social, psychological and biomedical research about incontinence, research about the fundamental elements of care, care-dependent individuals' expectations about care, and values about dignity and care.

RELEVANCE TO CLINICAL PRACTICE

The in-depth exploration led to an understanding of the basis for continence care practices that centre on cleaning, containing and concealing residents' incontinence in some nursing homes. There is a need to review the quality of education for the aged care workforce about incontinence to ensure it equips them with a broad understanding of the fundamentals of care and how to enact dignity in continence care through a resident-centred approach.

Urinary tract infection: a cohort of older people with urinary incontinence

ABSTRACT Objective: To evaluate epidemiological aspects of urinary tract infection in older patients with urinary incontinence living in long-term care institutions in Belo Horizonte. Method: Concurrent cohort held from April 1st to October 1st, 2015. The study was conducted in two long-term care institutions in the city of Belo Horizonte, Minas Gerais, with 84 incontinent older people. Results: Cumulative incidence of urinary tract infection was 19% (95% CI: 7.83-23.19) and the incidence density was 3.6 cases/100 people-month of follow-up period. The variables Bacteriuria and Institution presented statistical association with the occurrence of urinary tract infection. Conclusion: It is observed that the incidence of urinary tract infection in the study was smaller than in other similar international and national studies, however this is an important world health problem for the older population, with impact on mortality of these individuals.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set

Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Urinary incontinence in institutionalized elderly: prevalence and impact on quality of life

AbstractIntroduction Urinary incontinence is a geriatric syndrome that generates strong economic and social impacts as well as emotional changes and negative consequences for the health of the elderly.Objective The objective of this work was to identify the prevalence of urinary incontinence and its associated factors, as well as its impact on quality of life of institutionalized elderly.Materials and methods A cross-sectional study was conducted herein, with 10 long-term institutions for the elderly of the municipality of Natal (Northeast Brazil). The Minimum Data Set was completed by caregivers to determine the presence of incontinence, and the Short Form of the International Consultation on Incontinence Questionnaire was answered by the elderly, to assess the frequency and amount of urinary leakage, the impact on quality of life, and the type of incontinence. The chi-square test and Fisher’s exact test were applied in the bivariate analysis, and logistic regression was utilized for multivariate analysis.Results The prevalence of urinary incontinence was 42.7% (95% CI: 34.8–50.8). The impact of this condition on daily life was mild in 46.5% of cases, moderate for 29.3% of cases, and severe in 24.1% of cases. The condition was associated with functional impairment (p < 0.001; RP: 4.13).Final considerations The prevalence of urinary incontinence in this sample, which presented cognitive ability to answer questionnaires, was over 40% with a high degree of severity. Approximately half of the incontinents referred a moderate-severe impact of incontinence. Control measures for this geriatric syndrome within the institutions are important to delay the decline of health and improve the quality of life of the residents.

Behavioral Characteristics of Bowel Movement and Urination Needs in Patients With Dementia in Taiwan

Patients with dementia, especially those with advanced dementia, may not be able to express their bowel movement and urination needs using lucid language, and instead do so through behaviors. The aim of the current study was to understand and compare the behavioral characteristics of bowel movement and urination needs in patients with dementia. Observations were made by caregivers of 187 patients with dementia based on the Behavior Checklist developed by the research team for bowel movement and urination. Sixteen behavioral characteristics were identified for both bowel movement and urination; among these, anxiety, taking off/putting on clothes inappropriately, restlessness, attempting to go elsewhere, scratching skin, repeated behavior, and making strange sounds were commonly reported. Facial expressions of sorrow, restlessness, and anxiety were the three most common behaviors related to bowel movement needs, whereas anxiety, taking off/putting on clothes inappropriately, and constant moaning were the most common behaviors for urination needs. The findings suggest that the common behavioral characteristics could be seen as indicators of excretion need and the others can be used to distinguish between the need for bowel movement and urination.

Prevalence of urinary incontinence and associated factors in nursing home residents

AIMS

To determine the prevalence of urinary incontinence (UI) and associated factors in the institutionalized elderly.

METHODS

A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes in the city of Natal (Northeast Brazil). Individuals over the age of 60, who reside in institutions, were included. Hospitalized individuals and those at end of life were excluded. Data collection included sociodemographic information, UI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity, and Pfeiffer test for cognitive status). UI was verified through the Minimum Data Set (MDS) version 3.0, which was also used to assess urinary devices and UI toileting programs. The Chi-square test (or Fisher's exact test), the linear Chi-square test, and logistic regression were utilized to model associations.

RESULTS

The final sample consisted of 321 elderly, mostly females, with a mean age of 81.5 years. The prevalence of UI was 58.88% (CI 95%: 53.42-64.13) and the final model revealed a statistically significant association between UI and white race, physical inactivity, stroke, mobility impairment, and cognitive decline. The most frequent UI type was functional UI and toileting programs (prompted voiding) were only applied to approximately 8% of residents.

CONCLUSIONS

It is concluded that UI is a health issue that affects more than half of the institutionalized elderly, and is associated with white race, physical inactivity, stroke, and other geriatric syndromes such as immobility and cognitive disability.

Pad count is a poor measure of the severity of urinary incontinence

PURPOSE

We analyzed the correlation between pad use, as determined by objective pad count, and the severity of urinary incontinence, as measured by pad weight.

MATERIALS AND METHODS

We performed a retrospective study of consecutive incontinent patients who wore pads on a daily basis and were instructed to complete a 24-hour pad test. They were told to use the usual pads, change them as usual and place each in a separate plastic bag the day before the scheduled appointment. All pads were weighed and total urine loss was calculated by subtracting dry pad weight from wet pad weight, assuming that a 1 gm weight increase was equivalent to 1 ml of urine loss. The number of pads was correlated to pad weight using the Spearman rank correlation coefficient due to the nonparametric nature of the data.

RESULTS

The 116 patients included 51 men 39 to 89 years old (mean age 66) and 65 women 27 to 95 years old (mean age 72). When comparing the number of pads used to the gm of urine lost, the Spearman ρ was 0.26 (p=0.005) in the total cohort, and 0.40 and 0.26 (each p<0.05) in males and females, respectively.

CONCLUSIONS

There was little correlation between the number of pads used and the severity of urinary incontinence (r=0.26). These data suggest that pad count should not be used as an objective measure of incontinence severity. Instead, pad weight on a 24-hour pad test should be used.

An insight into continence management in patients with dementia

This article discuses the prevalence of urinary and faecal incontinence in people with dementia. The content explores the physiological changes affecting the older bladder and bowel together with the psychological and behavioural problems associated with dementia that impact on continence.

Neurogenic bladder

Congenital anomalies such as meningomyelocele and diseases/damage of the central, peripheral, or autonomic nervous systems may produce neurogenic bladder dysfunction, which untreated can result in progressive renal damage, adverse physical effects including decubiti and urinary tract infections, and psychological and social sequelae related to urinary incontinence. A comprehensive bladder-retraining program that incorporates appropriate education, training, medication, and surgical interventions can mitigate the adverse consequences of neurogenic bladder dysfunction and improve both quantity and quality of life. The goals of bladder retraining for neurogenic bladder dysfunction are prevention of urinary incontinence, urinary tract infections, detrusor overdistension, and progressive upper urinary tract damage due to chronic, excessive detrusor pressures. Understanding the physiology and pathophysiology of micturition is essential to select appropriate pharmacologic and surgical interventions to achieve these goals. Future perspectives on potential pharmacological, surgical, and regenerative medicine options for treating neurogenic bladder dysfunction are also presented.