Future directions for incontinence research with frail elders

Understanding the Impact of Urinary Incontinence in Persons with Dementia: Development of an Interdisciplinary Service Model

Introduction

Prevalence of urinary symptoms such as incontinence (UI) in patients with dementia is estimated to exceed 50%. The resultant psychological and socio-economic burden can be substantial. Our aim was to develop a dedicated urology service within a cognitive impairment clinic in order to treat and better understand the bothersome urinary symptoms suffered by persons with dementia.

Methods

Patients attending this clinic were invited to be assessed and interviewed by urologist, together with their family and/or carer. In addition, formal history, examination and relevant investigations, themes of importance such as quality of life, and select question items were drawn from validated questionnaires. Multidisciplinary team (MDT) meeting was carried out on the same day. Outcomes of the first 75 patients with UI and dementia have been reported.

Results

Average age was 70 years (range 58-98). Majority of persons had a diagnosis of Alzheimer's disease (n = 43, 57%). Average score for how much urine leakage interferes with everyday life was 7.7/10 (range 2-10). 58.7% (n = 44) revealed some degree of sleep disturbance due to UI. 83% (n = 62) stated daily activities were limited due to UI. Two-thirds of persons with dementia (n = 50) stated their bladder problem makes them feel anxious. 88% (n = 67) felt the topic was socially embarrassing. All carers stated that the person's continence issues affect the care they provide. Less than one-third of carers (30.7%, n = 23) were aware of or had been in contact with any bladder and bowel community service. More than half of the carers (n = 46, 65%) were concerned incontinence may be a principal reason for future nursing home admission.

Conclusion

UI can be distressing for persons with dementia. Care partners were concerned about loss of independence and early nursing home admission. Awareness of bladder and bowel services should be increased.

Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve

There is a misconception that urinary incontinence (UI) in older adults, usually above the age of 65 is a part of aging. More than 50% of residents in long-term care (LTC) settings are affected by UI and it is associated in many cases with markedly reduced quality of life. It has become evident that incontinence can be cured or successfully managed. However, many nurses lack sufficient knowledge to intervene appropriately. The purpose of this review is to share how the collaborative efforts of nurses at all levels may lead to increased assessment and interventions of UI in this population.

Fecal Incontinence Is Associated With Mortality Among Older Adults With Complex Needs: An Observational Cohort Study

OBJECTIVES

Fecal incontinence (FI) is a problem in growing older populations. Validating a suspected association between FI and mortality in community dwelling older adults could lead to improved planning for and management of the increasing complex older population. In a large cohort of New Zealand older adults, we assessed the prevalence of FI, urinary incontinence (UI), combined FI and UI, and their associations with mortality.

METHODS

This study consisted of a retrospective analysis of international standardized geriatric assessment-home care (InterRAI-HC) data from community-dwelling adults aged 65 years or older, who met the criteria required for the InterRAI-HC, having complex needs and being under consideration for residential care. The prevalence of UI and FI was analyzed. Data were adjusted for demography and 25 confounding factors. Mortality was the primary outcome measure.

RESULTS

The total cohort consisted of 41,932 older adults. Both UI and FI were associated with mortality (P<0.001), and risk of mortality increased with increased frequency of incontinence. In the adjusted model, FI remained significantly related to survival (P<0.001), whereas UI did not (P=0.31). Increased frequency of FI was associated with an increased likelihood of death (hazard ratio 1.28).

CONCLUSIONS

This large national study is the first study to prove a statistically significant relationship between FI and mortality in a large, old and functionally impaired community. These findings will help improve the management of increasingly complex older populations.

Defeating Urinary Incontinence with Exercise Training: Results of a Pilot Study in Frail Older Women

OBJECTIVES

To determine whether combining behavioral urinary incontinence (UI) treatments with physical activity improves UI in frail older women.

DESIGN

Single-blind, two-arm pilot randomized controlled trial.

SETTING

Senior apartments.

PARTICIPANTS

Frail women (mean age 84.9 ± 6.4) without dementia (n = 42).

INTERVENTION

Twelve-week program of customized behavioral UI treatments: 150 minutes of weekly walking and twice weekly strength training classes.

MEASUREMENTS

UI was measured using 3-day bladder diaries, the International Consultation on Incontinence Questionnaire (ICIQ), and UI global improvement questions. Toileting skills were measured using the Performance Oriented Timed Toileting Instrument (POTTI) and the Minnesota Toileting Skills Questionnaire (MTSQ). Physical function was measured using the Short Physical Performance Battery. UI-related quality of life was measured using the Incontinence Impact Questionnaire and Urogenital Distress Inventory.

RESULTS

The treatment group reported a 50% reduction in daily leaks using bladder diaries, and the control group reported no change (P = .04). Although there were no group differences in total ICIQ scores (P = .66), the treatment group reported significantly greater improvement on the ICIQ item for urine leakage (P = .01). More than 81% of the treatment group and 36% of the control group reported improvement in UI (χ² = 4.84, P = .01), with mean estimated percentage improvement of 65.3 ± 32.0 versus 34.1 ± 41.3 (P = .03). Although the difference was not statistically significant, treatment group participants improved their toileting skills, whereas those of the control group declined (P = .42 POTTI, P = .11 MTSQ). Balance (P = .33) and gait (P = .24) improved more in the treatment group, whereas chair stands improved more in the control group (P = .14).

CONCLUSION

UI may be improved in frail older women by combining behavioral strategies for UI with physical activity, but larger trails are needed to determine whether these findings can be replicated and sustained.

Translating research into prosthetic and orthotic practice

BACKGROUND

Evidence-based practice is commonly accepted as a means of improving patient outcomes; however, there is little understanding of the processes required to successfully implement it into prosthetic and orthotic practice.

OBJECTIVES

To discuss factors affecting adoption of evidence-based practice and present a theoretical framework for its implementation into prosthetic and orthotic practice.

DISCUSSION

Numerous factors that affect adoption of evidence-based practice are discussed, ranging from individual factors to those that can be attributed to administrative and environmental issues. Specific factors are likely to be context specific and are influenced by the manner in which evidence-based practice is introduced into the working environment. It is argued that successful implementation of evidence-based practice requires consideration of numerous interrelated factors. A formal translating research into practice model is presented as a means of developing a strategic plan that considers all relevant factors and maximizes acceptance of evidence-based practice into prosthetics and orthotics clinical practice.

CONCLUSIONS

The use of a theoretical model for implementation of evidence-based practice is likely to improve its adoption by prosthetic and orthotic clinicians. Clinical relevance The demand for prosthetists/orthotists to utilize evidence-based practice is increasing. Lack of strategic planning throughout the implementation phase is likely to compromise adoption of evidence-based practices by clinicians.

How do people make continence care happen? An analysis of organizational culture in two nursing homes

PURPOSE

Although nursing homes (NHs) are criticized for offering poor quality continence care, little is known about the organizational processes that underlie this care. This study investigated the influence of organizational culture on continence care practices in two NHs.

DESIGN AND METHODS

This ethnographic study explored continence care from the perspectives of NH stakeholders, including residents and interdisciplinary team members. Data were collected through participant observation, interviews, and archival records.

RESULTS

Human relations dimensions of organizational culture influenced continence care by affecting institutional missions, admissions and hiring practices, employee tenure, treatment strategies, interdisciplinary teamwork, and group decision making. Closed system approaches, parochial identity, and an employee focus stabilized staff turnover, fostered evidence-based practice, and supported hierarchical toileting programs in one facility. Within a more dynamic environment, open system approaches, professional identity, and job focus allowed flexible care practices during periods of staff turnover. Neither organizational culture fully supported interdisciplinary team efforts to maximize the bladder and bowel health of residents.

IMPLICATIONS

Organizational culture varies in NHs, shaping the continence care practices of interdisciplinary teams and leading to the selective use of treatments across facilities. Human relations dimensions of organizational culture, including open or closed systems, professional or parochial identity, and employee or job focus are critical to the success of quality improvement initiatives. Evidence-based interventions should be tailored to organizational culture to promote adoption and sustainability of resident care programs.

Development of a urinary incontinence educational program using a competency-based approach and case method

Nurses have limited knowledge about urinary incontinence and find it difficult to care for those who suffer from it, yet there is little training on incontinence designed for nurses. Hence, there is a real need to develop and evaluate an appropriate urinary incontinence educational program. A critical issue is the choice of teaching strategies designed to integrate learning. This article describes the competency-based approach and case method used to develop a urinary incontinence education program.

Randomized Trial of Oxybutynin Extended Versus Immediate Release for Women Aged 65 and Older with Overactive Bladder: Lessons Learned from Conducting a Trial

OBJECTIVE

This trial was designed to investigate the effectiveness of extended release versus immediate release oxybutynin in reducing symptoms of overactive bladder in a community-dwelling female population over the age of 65.

METHODS

This was a prospective randomized 12-week, open-label study. The primary outcome was number of micturitions per 24 hours, 12 weeks after treatment. The a priori sample size estimate was 60 patients per group.

RESULTS

Of the 318 women approached, only 72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely because of recruitment difficulties and an interim analysis revealing the need for a much larger sample than had been estimated to show a significant difference between treatments. After 12 weeks of treatment, there was no difference between the oxybutynin extended release and immediate release groups in the number of micturitions per 24 hours or in other outcomes.

CONCLUSION

This study did not demonstrate differences between oxybutynin extended release and immediate release and in reducing symptoms of overactive bladder or quality of life, possibly because the study did not reach the necessary sample size. The difficulty in recruiting subjects for the trial likely resulted from the onerous study requirements (4 study visits required over 12 weeks) and the downtown location of the study centres: these factors would cause particular difficulties for women over age 65 with overactive bladder, for whom travelling may be a problem. Evidence is needed to guide prescribing for older patients, but designing research to obtain adequate sample sizes is difficult. Studies in older subjects should ensure that a much larger budget is allocated for recruitment than would be allocated for studies in younger subjects, that meticulous attention is paid to issues of transport and access, and that support is provided for subjects who agree to take part research.

Urinary incontinence: basic evaluation and management in the primary care office

With the increasing number of older adults in the population, the office-based clinician can expect to see more people with UI. Continued UI research is warranted, especially research that includes older adults who reside in the community and frail elderly women who are still living in the community. Better outcome measures should be developed to assess the effectiveness of interventions for UI. Reliance on information obtained from voiding diaries is used extensively, yet the reliability and validity for any specific instrument have not been tested with older adults. Hopelessness and spiritual distress, as precursors to health decline and how they impact on quality of life, should be studied in older adults with UI. Given the prevalence of UI, should it be considered a public health problem for which population-based interventions are used? What is known is that older adults demonstrate significant improvement in symptoms of UI when education, counseling, support, and encouragement in behavior management and lifestyle interventions are provided. When motivated and positive, even frail older adults experience improvement in the severity of urine leakage. Perhaps the single most important action that the office-based clinician can take is to start asking every older adult about UI and to follow with the basic approaches to evaluation and management described in this article.