National audit of continence care: adherence to National Institute for Health and Clinical Excellence (NICE) guidance in older versus younger adults with faecal incontinence

Incidence, Prevalence, and Risk for Urinary Incontinence for People with Dementia in the Community in Aotearoa New Zealand: An interRAI Study

OBJECTIVES

To identify 1-year period prevalence, 5-year incidence rate, and risks for urinary incontinence (UI) for people living with dementia.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Participants completed an International Residential Assessment Instrument Home Care (interRAI-HC) assessment in a 5-year period between August 1, 2016 and July 31, 2021 in Aotearoa New Zealand (N = 109,964).

METHODS

For prevalence analysis, a dementia cohort was selected for a 1-year period from August 1, 2020 to July 31, 2021 (n = 7775). For incidence analysis, participants in the dementia cohort were followed from the first dementia diagnosis during the 5-year period. Dementia was identified by combining diagnoses of "Alzheimer's disease" and "Dementia other than Alzheimer's disease." Participants were coded with UI if they were infrequently, occasionally, or frequently incontinent or if continence was managed with catheter/ostomy. Univariate and multivariate logistic regression analyses identified risk factors predicting UI onset. Cox regression analysis compared survival curves (months without UI) of the dementia and non-dementia cohorts, adjusting for variables significantly associated with incident UI in either cohort.

RESULTS

The 1-year period (August 1, 2020 to July 31, 2021) prevalence of UI was 50.1% among people with dementia. The 5-year incident UI rate was 30.2 per 100 person-years for the dementia cohort and 24.5 per 100 person-years for the non-dementia cohort. Parkinson's disease posed the greatest risk of UI in both cohorts [dementia cohort odds ratio (OR), 3.0; 95% CI, 2.1-4.2; non-dementia cohort OR, 1.7; 95% CI, 1.4-2.0]. Controlling for risk factors, the hazard ratio for UI was 1.4 for people with dementia.

CONCLUSIONS AND IMPLICATIONS

UI affects a significant proportion of people with dementia in Aotearoa New Zealand. Health professionals should directly ask about UI and consider living arrangements and comorbidities for people with dementia. Data-driven insights from interRAI-HC can guide resource allocation and service planning.

Epidemiology of Faecal Incontinence for People with Dementia Living in the Community in New Zealand: A Retrospective Cohort Study Using interRAI Home Care Assessment Data

INTRODUCTION

Globally, there are few studies but wide variation in the epidemiology of faecal incontinence (FI) for people living with dementia in the community. Our objectives are to identify 1-year period prevalence, 5-year incidence, and risks for FI for people living with dementia.

METHODS

A retrospective cohort study comprising the International Residential Assessment Instrument Home Care version (interRAI-HC) assessments in a 5-year period in New Zealand (N = 109,964). For prevalence analysis, we selected a dementia cohort for a 1-year period from August 1, 2020, to July 31, 2021 (n = 7,775). For the incidence analysis, participants in the dementia cohort were followed up from the day of the first dementia diagnosis during the period August 1, 2016, and July 31, 2021. Dementia was identified by combining diagnosis of "Alzheimer's disease" and "Dementia other than Alzheimer's disease." Participants were coded with faecal incontinence if they were continent with a stoma, seldom incontinent, occasionally incontinent, often incontinent and incontinent.

RESULTS

One year period (1 August 2020-31 July 2021) prevalence of FI was 26.7% (2,082/7,775) of people with dementia. 5-Year incident FI rate was 19.0 per 100 person-years for people with dementia and 12.3 per 100 person-years for people without dementia. Controlling for risk factors for FI in both groups the hazard ratio for FI was 1.7 for people with dementia.

CONCLUSION

FI affects a significant proportion of people with dementia in New Zealand. interRAI-HC data could facilitate global epidemiological studies to estimate service or intervention needs for people with dementia to redress or manage FI.

Effectiveness of non-pharmacological interventions delivered at home for urinary and faecal incontinence with homebound older people: systematic review of randomised controlled trials

INTRODUCTION

Incontinence is a common, distressing condition, most prevalent in older people. There is an unmet need for effective interventions to support continence. This review focuses on non-pharmacological interventions to reduce incontinence among homebound older people. Aim: to identify interventions with potential to be delivered by care workers, nurses or family members in a person's home.

METHODS

Multiple databases were searched until 15 September 2023 for randomised controlled trials reporting home-based interventions for incontinence for older people (≥65 years) living at home. Two reviewers independently screened titles, abstracts and papers against inclusion criteria, then assessed for the Risk of Bias (RoB2). A third reviewer resolved the discrepancies. Primary data were extracted and synthesised.

RESULTS

A full-text review of 81 papers identified seven eligible papers (1996-2022, all USA), including n = 636 participants (561 women and 75 men). Two studies focusing on multicomponent behavioural interventions showed benefit, as did one study of transcutaneous tibial nerve stimulation self-administered through electrode-embedded socks. Three, which included cognitively impaired people, reported improvement with toileting assistance programmes, but the effects were not all significant. Results were inconclusive from a study examining the effects of fluid intake adjustments. Interventions were delivered by nurses, three in collaboration with family caregivers. No faecal incontinence interventions met the criteria.

CONCLUSION

There is scant evidence for continence supporting interventions delivered in older people's own homes. With an ageing population often reliant on family or social care workers well-placed to support continence promotion and policy drives for services to support older people remaining at home, this evidence gap needs addressing.

Incontinence in people living with dementia

Dementia and incontinence are both prevalent in older age; yet, neither are an inevitable or normal part of ageing. It has been recognised that there is a skills and knowledge gap in professionals assessing and managing incontinence for people living with dementia. All too often, assumptions are made that incontinence is a symptom of dementia and that nothing can be done if a person living with dementia experiences episodes of incontinence. While dementia may impact on a person's ability to remain continent, it may not be the sole cause, and there may be treatments and strategies that can reduce the incidence in those affected. Therefore, a person-centred continence assessment should be undertaken to promote continence and reduce the impact of incontinence for people living with dementia and those who care for them. This paper will highlight some of the issues that are important for health and social care professionals to explore and identify, assess and manage incontinence to improve outcomes for families affected by dementia.

Identifying incontinence and promoting continence in people living with dementia

Urinary and faecal incontinence are more prevalent among older people but, like dementia, incontinence is not a normal or inevitable part of ageing. The number of people living with dementia who experience continence issues is likely to be underestimated because many people avoid reporting them as a result of embarrassment and stigma, or because they think incontinence is an inevitable symptom of dementia and that nothing can be done about it. Increased awareness and understanding of the relationship between dementia and incontinence is needed so that nurses can persuade people living with dementia and their family carers to discuss continence issues, assess their needs and provide support. There are several practical strategies that can reduce the incidence of incontinence, counter its negative effects and promote continence in people living with dementia.

Hospital practitioner views on the benefits of continence education and best ways to provide training

AIM

The aim of the study was to explore practitioners' experiences and perspectives on continence training, in order to understand its relevance to practice and how take-up of, and engagement with, such training may be improved.

DESIGN

27 qualitative interviews were conducted with nursing, medical and allied health practitioners in three hospitals.

METHODS

We analysed data thematically, both manually and with the aid of NVivo software. The research adheres to the consolidated criteria for reporting qualitative research checklist.

RESULTS

Practitioners asserted the likely benefits of evidence-based continence training, including more judicious use of products, reduction in associated infection, better patient skin care and more facilitative communication with patients. Practitioners also identified preferred methods of continence training, according to their role and workload. To ensure better take-up of, and engagement with, continence training, it must be authorized as essential and provided in ways that reflect professional preferences and pragmatic resource considerations.

'We tend to get pad happy': a qualitative study of health practitioners' perspectives on the quality of continence care for older people in hospital

Background

Bladder and bowel control difficulties affect 20% and 10% of the UK population, respectively, touch all age groups and are particularly prevalent in the older (65+ years) population. However, the quality of continence care is often poor, compromising patient health and well-being, increasing the risk of infection, and is a predisposing factor to nursing and residential home placement.

Objective

To identify factors that help or hinder good continence care for patients aged 65 years and over in hospital medical ward settings. Medical care, not surgical, was our exclusive focus.

Methods

We conducted 27 qualitative interviews with nursing, medical and allied health practitioners in three hospitals. We used a purposive sample and analysed data thematically, both manually and with the aid of NVivo software.

Results

Interviews revealed perspectives on practice promoting or inhibiting good quality continence care, as well as suggestions for improvements. Good continence care was said to be advanced through person-centred care, robust assessment and monitoring, and a proactive approach to encouraging patient independence. Barriers to quality care centred on lack of oversight, automatic use of incontinence products and staffing pressures. Suggested improvements centred on participatory care, open communication and care planning with a higher bladder and bowel health profile. In order to drive such improvements, hospital-based practitioners indicate a need and desire for regular continence care training.

Conclusions

Findings help explain the persistence of barriers to providing good quality care for patients aged 65 years and over with incontinence. Resolute continence promotion, in hospitals and throughout the National Health Service, would reduce reliance on products and the accompanying risks of patient dependency and catheter-associated gram-negative bacteraemia. Robust assessment and care planning, open communication and regular continence care training would assist such promotion and also help mitigate resource limitations by developing safer, time-efficient continence care.

Incontinence in frail elderly persons: Report of the 6th International Consultation on Incontinence

BACKGROUND

Evidence-based guidelines for the management of frail older persons with urinary incontinence are rare. Those produced by the International Consultation on Incontinence represent an authoritative set of recommendations spanning all aspects of management.

AIMS

To summarize the available evidence relating to the management of urinary incontinence in frail older people published since the 5th International Consultation on Incontinence.

MATERIALS AND METHODS

A series of systematic reviews and evidence updates were performed by members of the working group to update the 2012 recommendations.

RESULTS

Along with the revision of the treatment algorithm and accompanying text, there have been significant advances in several areas of the management of lower urinary tract symptoms in frail older people.

DISCUSSION

The committee continues to note the relative paucity of data concerning frail older persons and draw attention to knowledge gaps and research opportunities. Clinicians treating older people with lower urinary tract symptoms should use the available evidence from studies of older people combined with careful extrapolation of those data from younger subjects. Due consideration to an individual's frailty and wishes is crucial.

Assessment, prevention and treatment of faecal incontinence in older people

Faecal incontinence is an impaired ability to control the passage of stool, often described as involuntary loss of solid or liquid stool, and the symptom of an underlying diagnosis. It is a common problem in older adults. Although not a life-threatening condition, it can have a significant negative effect on an individual's quality of life and adverse medical, social and economic consequences. Due to the taboo and stigmatising nature of the condition many individuals do not seek assistance. Healthcare professionals should take every opportunity to ask about faecal incontinence symptoms so that symptomatic relief and treatment interventions can be initiated. There are several conservative approaches available for the treatment of faecal incontinence, which should be considered as first line to target symptomatic relief.

Have you SCAND MMe Please? A framework to prevent harm during acute hospitalisation of older persons: A retrospective audit

AIMS AND OBJECTIVES

To test the mnemonic Have you SCAND MMe Please? as a framework to audit nursing care to prevent harms common to older inpatients.

BACKGROUND

It is not known if acute hospital care comprehensively addresses eight interrelated factors that contribute to preventable harms common in older hospitalised patients.

DESIGN

Retrospective audit of medical records.

METHODS

A random selection of 400 medical records of inpatients over 65 years of age with an unplanned admission of longer than 72 hr in acute medical wards at four hospitals in Victoria, Australia, during 2011-12, was examined for frequency of documented evidence of assessments, interventions or new problems related to eight factors contributing to common preventable harms during hospitalisation.

RESULTS

Assessments of skin integrity (94%-97%), mobility (95%-98%) and pain (93%-97%) were most often documented. Gaps in assessment of continence (4%-31%), nutrition (9%-49%), cognition (delirium, depression and dementia) (10%-24%) were most common. No patient record had evidence of all eight factors being assessed. Almost 80% of records had interventions documented for one or more factors that contribute to preventable harms. In almost 20% of patient records, a new preventable harm was documented during hospitalisation.

CONCLUSIONS

The mnemonic Have you SCAND MMe Please? brings together eight factors known to contribute to preventable harms common in older hospitalised patients. This framework was useful to identify gaps in assessment and interventions for factors that contribute to preventable harms during acute hospital care. Future research should test if the mnemonic can assist nurses with comprehensive harm prevention during acute hospitalisation.

RELEVANCE TO CLINICAL PRACTICE

The mnemonic Have you SCAND MMe Please? represents eight factors that contribute to preventable harms common in older hospitalised patients. This framework provides a model for harm prevention to assist nurses to implement comprehensive harm prevention to improve quality of care and safety for older hospitalised patients.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Initiative to improve detection of faecal incontinence in primary care: The GIFT Project

BACKGROUND

Faecal incontinence (FI) is a distressing condition with a significant impact on quality of life. The true prevalence of FI is unknown but probably underestimated. Identifying patients affected is of key importance because a significant proportion may improve with conservative treatments, and there are a number of other treatments available.

OBJECTIVES

The aim of our project was to improve detection of FI in our primary care setting.

METHODS

A multidisciplinary working group was created in order to raise awareness and educate health professionals about FI. We designed a simple protocol and organized educational meetings at 7 primary care centres. The usual diagnostic computer-based tools used by nurses were modified, so that FI was systematically asked about. A proactive attitude among doctors and midwives regarding FI was recommended for high-risk patient groups.

RESULTS

The project was implemented in October 2014. Before the intervention, only 250 (<1%) patients with a diagnosis of FI were identified from the primary care register out of a population over 165000 people. Between October 2014 and February 2016, 17370 patients were questioned about anal continence in routine follow-ups. Of those questioned, 829 (4.8%) disclosed suffering from FI. Mean age was 78.5 ± 14 years (16-104), 565 (68.2%) were females, and 264 (31.8%) were males. The percentage of patients with FI increased with age and was higher in women.

CONCLUSION

Our results show that a proactive approach with direct questions on FI may lead to a significant increase in FI detection in primary care.

Incontinence-associated dermatitis: reducing adverse events

Incontinence-associated dermatitis (IAD) is a common problem in patients with faecal and/or urinary incontinence. Urine alters the normal skin flora and increases permeability of the stratum corneum and faecal enzymes on the skin contribute to skin damage. Faecal bacteria can then penetrate the skin, increasing the risk of secondary infection. However, IAD can be prevented and healed with timely and appropriate skin cleansing and skin protection. This includes appropriate use of containment devices. This article also looks at HARTMANN incontinence pads that have been developed to absorb the fluids that cause IAD and maintain the skin's acidic pH. The acidic pH of the skin contributes to its barrier function and defence against infection. Therefore, maintaining an acidic pH will help protect the skin from damage.

Loperamide Versus Psyllium Fiber for Treatment of Fecal Incontinence: The Fecal Incontinence Prescription (Rx) Management (FIRM) Randomized Clinical Trial

BACKGROUND

Fecal incontinence is a devastating condition with few US Food and Drug Administration-approved pharmacologic treatment options. Loperamide and psyllium, both first-line treatments, have different mechanisms of action without any comparative data.

OBJECTIVE

The purpose of this study was to examine the effectiveness and tolerability of loperamide compared with psyllium for reducing fecal incontinence. We hypothesized that psyllium fiber supplementation would be more effective than loperamide for reducing fecal incontinence episodes and have fewer adverse effects.

DESIGN

We conducted a randomized, double-blind, placebo-controlled crossover trial comparing loperamide (followed by psyllium) with psyllium (followed by loperamide).

SETTINGS

Our sites included outpatient clinics within a Veterans Affairs medical center and university affiliate.

PATIENTS

Participants included community-dwelling adults (n = 80) with at least 1 fecal incontinent episode on a 7-day bowel diary.

INTERVENTION

Participants received either daily loperamide (plus placebo psyllium powder) or psyllium powder (plus loperamide placebo) for 4 weeks. After a 2-week washout, participants crossed over to 4 weeks of alternate treatment.

MAIN OUTCOME MEASURES

The primary outcome was the number of fecal incontinence episodes from 7-day bowel diaries. Secondary outcomes included symptom severity, quality of life, and tolerability.

RESULTS

Mean age was 60.7 ± 10.1 years; 68% were men. After determining nonsignificant carryover effects, combined analyses showed no differences between the loperamide and psyllium groups for reducing fecal incontinent episodes, symptom severity, or quality of life. Within each group, both loperamide and psyllium reduced fecal incontinent episodes and improved symptom severity and quality of life. Constipation occurred in 29% of participants for loperamide vs 10% for psyllium.

LIMITATIONS

Limitations include the washout period length and dropout rate after crossing over to the second intervention.

CONCLUSIONS

Both loperamide and psyllium improve fecal incontinence. Loperamide was associated with more adverse effects, especially constipation.

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands

Objective

Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands.

Method

A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs.

Results

With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved.

Conclusion

Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furthermore, the study also highlighted that various areas of the continence care process lack data, which would be valuable to collect through the introduction of the NS in a study setting.

Reducing and managing faecal incontinence in people with advanced dementia who are resident in care homes: protocol for a realist synthesis

INTRODUCTION

Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes.

METHODS AND ANALYSIS

A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be 'tested' through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1.

ETHICS AND DISSEMINATION

The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.