Systematic reviews of bladder training and voiding programmes in adults: a synopsis of findings on theory and methods using metastudy techniques

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.

Feasibility of Tele-Prompt: A tablet-based prompted voiding intervention to support informal caregivers of older adults with urinary incontinence

Urinary incontinence (UI) is a highly prevalent condition, burdening older adults and their informal caregivers. This study explored the development and feasibility of a 6-week evidence-based, educational/skill building program delivered via tablet-personal computer aimed at developing informal caregiver UI knowledge; and enhancing informal caregiver skill set in prompted voiding and toileting strategies. Caregivers also received individualized weekly coaching sessions from a nurse expert. Feasibility and preliminary efficacy were tested in three caregiver/care-recipient dyads. Recruitment of eligible participants through community-based resources was a challenge to feasibility. Most caregivers found the technology acceptable, but adherence to prompted voiding was inconsistent. All caregivers rated the intervention highly, reported improvements in their care-recipient's urine leakage, found access to a UI expert beneficial, and would recommend it to a friend. The results suggest that the tablet-facilitated intervention was feasible and acceptable to informal caregivers and showed promise for improving both caregiver and care recipient outcomes.

Client and clinical staff perceptions of barriers to and enablers of the uptake and delivery of behavioural interventions for urinary incontinence: qualitative evidence synthesis

AIM

To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff.

BACKGROUND

Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed.

DESIGN

Qualitative evidence synthesis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006-2013).

REVIEW METHODS

Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. We used an approach akin to Framework, using a matrix of pre-specified themes to classify the data and facilitate its presentation and synthesis.

RESULTS

Seven studies involving 200 participants identified clients' views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success.

CONCLUSION

There is little detailed exploration of clients' experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Evidence-Based Continence Care: An Integrative Review

PURPOSE

The purpose of this integrative review is to identify the best nurse-managed continence care strategies among rehabilitation patients from the current body of evidence.

DESIGN

The newly designed 2015 Competency Model for Professional Rehabilitation Nursing serves as a conceptual framework to categorize evidence-based recommendations for continence care into the four domains of the model.

METHODS

A search of the evidence was completed in December 2015. Literature reviewed was limited to articles published from 2005-2015 in the English language. Search priority was given to systematic reviews and randomized controlled trials.

FINDINGS

Nurse-led interventions include evidence-based clinical assessments with use of validated instruments following step-wise algorithms derived from clinical practice guidelines. The interprofessional team emphasizes role-based continence interventions with shared work to reach goals. Leadership recommendations call for administrative support and allocation of resources for continence care and also empower select bedside nurses to become continence champions. Finally, nurse-patient education and caregiver training target the promotion of successful living. System-based continence recommendations are identified to include rehab-oriented electronic documentation systems, written continence policies and procedures, and ongoing nursing education emphasizing accountability to high performance standards.

CONCLUSIONS

Rehabilitation nurses are the team leaders in promoting continence in the rehabilitation setting. They are the cultivators of hope and foster resilience among patients to move forward despite acute or chronic illness and disability. This article is intended to support rehabilitation nurses in their review of clinical evidence in effort to move toward a more uniform approach to bowel and bladder management.

CLINICAL RELEVANCE

This review equips rehabilitation nurses who seek to improve their practice by identifying the best evidence-based approaches to continence care.

Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care

Background

Urinary incontinence (UI) following acute stroke is common, affecting between 40% and 60% of people in hospital, but is often poorly managed.

Aim

To develop, implement and evaluate the preliminary effectiveness and potential cost-effectiveness of a systematic voiding programme (SVP), with or without supported implementation, for the management of UI after stroke in secondary care.

Design

Structured in line with the Medical Research Council framework for the evaluation of complex interventions, the programme comprised two phases: Phase I, evidence synthesis of combined approaches to manage UI post stroke, case study of the introduction of the SVP in one stroke service; Phase II, cluster randomised controlled exploratory trial incorporating a process evaluation and testing of health economic data collection methods.

Setting

One English stroke service (case study) and 12 stroke services in England and Wales (randomised trial).

Participants

Case study, 43 patients; randomised trial, 413 patients admitted to hospital with stroke and UI.

Interventions

A SVP comprising assessment, individualised conservative interventions and weekly review. In the supported implementation trial arm, facilitation was used as an implementation strategy to support and enable people to change their practice.

Main outcome measures

Participant incontinence (presence/absence) at 12 weeks post stroke. Secondary outcomes were quality of life, frequency and severity of incontinence, urinary symptoms, activities of daily living and death, at discharge, 6, 12 and 52 weeks post stroke.

Results

There was no suggestion of a beneficial effect on outcome at 12 weeks post stroke [intervention vs. usual care: odds ratio (OR) 1.02, 95% confidence interval (CI) 0.54 to 1.93; supported implementation vs. usual care: OR 1.06, 95% CI 0.54 to 2.09]. There was weak evidence of better outcomes on the Incontinence Impact Questionnaire in supported implementation (OR 1.22, 95% CI 0.72 to 2.08) but the CI is wide and includes both clinically relevant benefit and harm. Both intervention arms had a higher estimated odds of continence for patients with urge incontinence than usual care (intervention: OR 1.58, 95% CI 0.83 to 2.99; supported implementation: OR 1.73, 95% CI 0.88 to 3.43). The process evaluation showed that the SVP increased the visibility of continence management through greater evaluation of patients’ trajectories and outcomes, and closer attention to workload. In-hospital resource use had to be based on estimates provided by staff. The response rates for the postal questionnaires were 73% and 56% of eligible patients at 12 and 52 weeks respectively. Completion of individual data items varied between 67% and 100%.

Conclusions

The trial was exploratory and did not set out to establish effectiveness; however, there are indications the intervention may be effective in patients with urge and stress incontinence. A definitive trial is now warranted.

Study registration

This study is registered as ISRCTN08609907.

Funding details

The National Institute for Health Research Programme Grants for Applied Research programme. Excess treatment costs and research support costs were funded by participating NHS trusts and health boards, Lancashire and Cumbria and East Anglia Comprehensive Local Research Networks and the Welsh National Institute for Social Care and Health Research.

[Micturition and cognition]

PURPOSE

The physiopathology of the voiding and urinary continence was one of the hot topic of research these last few years. Unfortunately, anyone have already found a unique cause which could explain urinary incontinence (urge or stress). The concept of cognitive function highlights new ways of research to show the fundamental role of the cortex and the sub-cortex in these diseases.

METHODS

A comprehensive literature review using Pubmed, Medline, Embase and Cochrane: "cognition, urinary tract, urinary continence, neuroimaging, IRMf, micturition, urge, brain factor and cognitive therapy". In all the articles, 72 really dealt with micturition and cognition.

RESULTS

New imaging techniques allowed to show the relationship between the different brain area involved in the bladder control such as the periaqueductal gray, the hypothalamus, the insula, the anterior cingulated cortex and the prefrontal cortex. These cortical area are equally involved in cognition. An alteration of urinary continence implies a modification of activation of these cortical areas.

CONCLUSION

A better knowledge of the cognitive side of micturition and urinary continence will allow to improve the treatment of their associated diseases.

[Female urinary incontinence: a systematic review of qualitative studies]

Urinary incontinence has broad repercussions on female daily life. The objective of this study was to conduct a systematic review seeking to analyze results of qualitative research concerning female urinary incontinence published prior to 2009. After an electronic search, 53 research reports were identified with 30 fulfilling the exclusion and inclusion criteria. After classification according to the Critical Appraisal Skills Program, 13 constituted the analytical body for review. The data were synthesized according to the meta-ethnographical approach through reciprocal translation. Two categories emerged: life experiences among incontinent women; and proposals for care models for incontinent women. The restructuring of one's personal life metacategory points to individual adjustments necessary for dealing with the problem. In essence, the results reveal the option of the majority of women facing the loss of urine "silently" and point to the need for professionals to understand family perceptions in order to better comprehend the personal, family, and social implications involved in female urinary incontinence.

Study protocol: ICONS: identifying continence options after stroke: a randomised trial

BACKGROUND

Urinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients.

METHODS/DESIGN

A cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services will be randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation, or usual care. The trial aims to recruit at least 780 participants in 12 stroke services (4 per arm). The primary outcome is presence/absence of incontinence at six weeks post-stroke. Secondary outcomes include frequency and severity of incontinence, quality of life and cost-utility. Outcomes will be measured at six weeks, three months and (for participants recruited in the first three months) twelve months after stroke. Process data will include rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation will be conducted in order to describe implementation and assist in explaining the potential mediators and modifiers of the process.

TRIAL REGISTRATION

ISRCTN: ISRCTN08609907

Systematic review of the management of incontinence and promotion of continence in older people in care homes: descriptive studies with urinary incontinence as primary focus

AIM

This is a review of descriptive studies with incontinence as the primary focus in older people in care homes.

BACKGROUND

Incontinence is prevalent among residents of care home populations.

DATA SOURCES

MEDLINE and CINAHL were searched from 1996 to 2007 using the highly sensitive search strings of the Cochrane Incontinence Review Group for urinary and faecal incontinence including all research designs. Search strings were modified to enhance selectiveness for care homes and older people and exclude studies involving surgical or pharmacological interventions. Searching of reference sections from identified studies was also used to supplement electronic searches. The Cochrane Library was searched for relevant systematic reviews to locate relevant studies from those included or excluded from reviews. The search was limited to English-language publications.

METHODS

A systematic review of studies on the management of incontinence, promotion of continence or maintenance of continence in care homes was conducted in 2007-2009. This is a report of descriptive studies. Results. Ten studies were identified that reported on prevalence and incidence of incontinence (urinary with or without faecal), policies, assessment, documentation, management or economic evaluation of its management. Use of incontinence pads and toileting programmes comprised the most common management approaches used. No studies were identified that attempted to maintain continence of residents in care homes.

CONCLUSIONS

Studies on maintaining continence and identifying components of toileting programmes that are successful in managing or preventing incontinence and promoting continence in residents of care home populations along with their economic evaluation are warranted.