Prevalence and correlates of fecal incontinence among nursing home residents: a population-based cross-sectional study

The aging gut: Symptoms compatible with disorders of gut-brain interaction (DGBI) in older adults in the general population

BACKGROUND

Little is known about changes in gastrointestinal symptoms compatible with disorders of gut-brain interaction (DGBI) with increasing age at the population level. The objective of this study was to describe the patterns of DGBI in individuals 65 years of age and above and contrasting them with those of younger adults.

METHODS

A community sample of 6300 individuals ages 18 and older in the US, UK, and Canada completed an online survey. Quota-based sampling was used to ensure equal proportion of sex and age groups (40% aged 18-39, 40% aged 40-64, 20% aged 65+) across countries, and to control education distributions. The survey included the Rome IV Diagnostic Questionnaire for DGBI, demographic questions, questionnaires measuring overall somatic symptom severity and quality of life, and questions on healthcare utilization, medications, and surgical history.

RESULTS

We included 5926 individuals in our analyses; 4700 were 18-64 years of age and 1226 were ages 65+. Symptoms compatible with at least one DGBI were less prevalent in participants ages 65+ vs. ages 18-64 years (34.1% vs. 41.3%, p < 0.0001). For symptoms compatible with upper GI DGBI, lower prevalence for most disorders was noted in the 65+ group. For lower GI DGBI, a different pattern was seen. Prevalence was lower in ages 65+ for irritable bowel syndrome and anorectal pain, but no differences from younger participants for the disorders defined by abnormal bowel habits (constipation and/or diarrhea) were seen. Fecal incontinence was the only DGBI that was more common in ages 65+. Having a DGBI was associated with reduced quality of life, more severe non-GI somatic symptoms, and increased healthcare seeking, both in younger and older participants.

CONCLUSION

Symptoms compatible with DGBI are common, but most of these decrease in older adults at the population level, with the exception of fecal incontinence which increases. This pattern needs to be taken into account when planning GI health care for the growing population of older adults.

Faecal incontinence in adults

Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.

Fecal incontinence: incidence and risk factors from the SABE (Health, Wellbeing and Aging) study

INTRODUCTION AND HYPOTHESIS

This study aimed to estimate the incidence of fecal incontinence (FI) and identify risk factors in a cohort of older individuals.

METHODS

In 2006, individuals aged ≥ 60 years were selected from the SABE study. The dependent variable was FI in 2010. FI was assessed using the question: "In the last 12 months, have you ever lost control of bowel movements or stools?" Incidence was measured in units of per 1000 person-years. Multivariate analysis was used to assess risk factors for FI.

RESULTS

This study was the first to examine the incidence of FI in older Brazilian individuals. In total, 1413 individuals were included; mean age was 74.5 years, and 864 (61.8%) participants were women. FI prevalence rates were 4.7% for men and 7.3% for women. Incidence rate of FI was 16.3 and 22.2 per 1000 person-years for men and women, respectively. The risk of FI was greater among women aged ≥ 75 years, with severe symptoms of depression, cancer (other than skin) and chronic obstructive pulmonary disease (COPD). In men, the risk of FI was greater among those with poor literacy (up to 3 years of schooling), an Instrumental Activities of Daily Living (IADL) category of 1-4 and those who self-reported "bad/very bad" health status.

CONCLUSIONS

The FI incidence rate was high. The identified risk factors were age ≥ 75 years, with severe symptoms of depression, cancer and COPD (women); having up to 8 years of schooling; IADL category of 1-4 and self-reported health status (men).

Urinary incontinence and the impact on migrant individuals with intellectual disability

Enhancing and enriching the health and wellbeing of migrant individuals with intellectual disability is essential in our diverse society. The needs of this population can be substantial, but unfortunately migrant individuals with intellectual disability face many challenges, from accessing health services, cultural complexities, financial difficulties, and language barriers, to lack of knowledge on the availability of particular services. Although a common condition, urinary incontinence remains a taboo subject and many individuals do not seek intervention even though it impacts on all aspects of their life. The migrant individual who has an intellectual disability may be unable to understand information that is provided, unable to gain knowledge, access educational material to promote continence and manage incontinence. This article considers what is known on the subject of urinary incontinence for an individual with intellectual disability from the migrant community in Ireland.

The Role of Obesity on Urinary and Anal Incontinence in women: a review

Obesity is increasing worldwide with significant healthcare implications. We searched PubMed/MEDLINE, Embase and Cochrane Library for articles registered until June 2020 to explore the relationship between obesity, urinary (UI) and anal incontinence (AI). Obesity is associated with low-grade, systemic inflammation and pro-inflammatory cytokine release, producing reactive oxygen species and oxidative stress (1). This alters collagen metabolism and, in combination with increased intraabdominal pressure, contributes to UI development. Whereas in AI, stool consistency may be a factor. Weight loss can reduce UI and should be a management focus, however effect on AI is less clear. Keywords: Obesity, Urinary incontinence, Anal incontinence.

Fecal Incontinence in the Elderly

Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.

Which Characteristics of Fecal Incontinence Predispose Incontinence-Associated Dermatitis? A Classification and Regression Tree Analysis

OBJECTIVE

To investigate which characteristics of fecal incontinence (FI) are predictors for incontinence-associated dermatitis (IAD) using the Classification and Regression Tree method.

DESIGN AND SETTING

Data collected from 2014 to 2016 during the Austrian Nursing Quality Measurement 2.0, an annually conducted, cross-sectional, multicenter prevalence study, were merged and analyzed.

MAIN OUTCOME MEASURE

The duration, frequency, and amount of FI were used as predictors for IAD. Nurses were asked if the participants suffered from IAD based on their clinical judgment (yes/no).

MAIN RESULTS

In total, 1,513 participants with FI were included in this analysis. More than 75% of the participants with FI were to a great extent or completely care dependent. Of all FI participants, nearly 6% suffered from IAD, and more than 70% received special skin care for IAD prevention. Participants with FI had the highest risk of developing IAD if they experienced FI every day, had FI for less than 3 months, and had developed the FI in their current institution.

CONCLUSIONS

Nurses face many challenges while helping patients with FI maintain healthy skin. Knowledge of the results of this study and accumulated knowledge about the specific characteristics of FI that are associated with the development of IAD can help healthcare personnel prevent IAD. Based on these results, improving patient education for persons with newly diagnosed FI to prevent IAD is recommended. Research studies should use the definition of FI established by the International Continence Society.

A concept analysis of dignity-protective continence care for care dependent older people in long-term care settings

Background

Although codes of conduct, guidelines and standards call for healthcare practitioners to protect patients’ dignity, there are widespread concerns about a lack of attention to the dignity of older people who need assistance with toileting, incontinence or bladder or bowel care in health or social care settings that provide long-term care. Incontinence and care dependence threatens patient dignity. The aim of this research was to explore, describe and explain the concept of dignity as it relates to continence care for older people requiring long-term care.

Methods

The first four steps of Rodgers evolutionary method of concept analysis were followed. First, a comprehensive and systematic search of databases and key guidelines about continence care was undertaken to identify empirical research about dignity and continence care in older people in facilities that provide permanent residential or inpatient care of older people for day-to-day living. Data were extracted on the authors, date, sample, country of origin, and key definitions, attributes, contexts and consequences from each included record. Findings were inductively analysed and grouped according to whether they were the key attributes and antecedents of dignity in relation to continence care or the consequences of undignified continence care.

Results

Of 625 articles identified, 18 were included in the final analysis. Fifty individual attributes were identified that were categorised in 6 domains (respect, empathy, trust, privacy, autonomy and communication). A further 15 were identified that related to the environment (6 physical and 9 social). Key consequences of undignified continence care were also identified and categorised into 3 levels of impact (resident/family member, staff or organisation).

Conclusions

This research resulted in a conceptual understanding of dignity that can be used as a value or guiding principle in an ethic of care for older people who need assistance with toileting, incontinence or bladder or bowel care in long-term care settings.

The mysteries of menopause and urogynecologic health: clinical and scientific gaps

OBJECTIVES

A significant body of knowledge implicates menopausal estrogen levels in the pathogenesis of the common pelvic floor disorders (PFDs). These health conditions substantially decrease quality of life, increase depression, social isolation, caregiver burden, and economic costs to the individuals and society.

METHODS

This review summarizes the epidemiology of the individual PFDs with particular attention to the understanding of the relationship between each PFD and menopausal estrogen levels, and the gaps in science and clinical care that affect menopausal women. In addition, we review the epidemiology of recurrent urinary tract infection (rUTI)-a condition experienced frequently and disproportionately by menopausal women and hypothesized to be potentiated by menopausal estrogen levels.

RESULTS

The abundance of estrogen receptors in the urogenital tract explains why the natural reduction of endogenous estrogen, the hallmark of menopause, can cause or potentiate PFDs and rUTIs. A substantial body of epidemiological literature suggests an association between menopause, and PFDs and rUTIs; however, the ability to separate this association from age and other comorbid conditions makes it difficult to draw definitive conclusions on the role of menopause alone in the development and/or progression of PFDs. Similarly, the causative link between the decline in endogenous estrogen levels and the pathogenesis of PFDs and rUTIs has not been well-established.

CONCLUSIONS

Innovative human studies, focused on the independent effects of menopausal estrogen levels, uncoupled from tissue and cellular senescence, are needed.

ACOG Practice Bulletin No. 210: Fecal Incontinence

Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7-15% of community-dwelling women (1). It is associated with reduced quality of life, negative psychologic effects, and social stigma (2), yet many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal incontinence will have this diagnosis recorded in their medical record (3). Obstetrician-gynecologists are in a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women. The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and management of fecal incontinence to help obstetrician-gynecologists diagnose the condition and provide conservative treatment or referral for further work up and surgical management when appropriate. For discussion on fecal incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacerations at Vaginal Delivery (4).

Inhibition of hyperplasia during the implantation of the puborectalis-like artificial anal sphincter

OBJECTIVES

This study aims to extend the implantation lifetime of the puborectalis-like artificial anal sphincter by inhibiting the occurrence of hyperplasia following the implantation process.

METHOD

A new transmission structure was designed inside the puborectalis-like artificial anal sphincter to generate an adequate torque to maintain the feces, even if hyperplasia developed around the prosthetic sphincter. An outer shell was added to the prosthetic sphincter to decelerate the occurrence of hyperplasia on the outer shell side. Medical titanium alloy was tested to replace the nylon-12 prosthetic sphincter, while polyetheretherketone was used for the construction of the power supply unit in the puborectalis-like artificial anal sphincter system instead of nylon-12. In vivo experiments were conducted to evaluate all the methods presented in this study with 10 Pa Ma piglets, 1 domestic pig, and 1 beagle dog during the past 2 years.

RESULTS

Compared with the previous prosthetic sphincter that was equipped with a fixed-axle gear transmission, the new transmission structure is equipped with a planet-gear train managed to generate a prosthetic sphincter output with a 53% larger torque but with the same size and type of motor as that used previously and increase the implantation lifetime by 56%. After the replacement of the nylon-12, the new prosthetic sphincter made of medical titanium alloy succeeded in extending the implanted lifetime by 83%. In addition, the lifetime was increased by 143%, when an outer shell was added to the prosthetic sphincter. Polyetheretherketone significantly decreased the growth rate of hyperplasia around the power supply unit by 44% after the replacement of the power supply unit material. After the combination of all the improvements, the longest implantation lifetime of the puborectalis-like artificial anal sphincter during the in vivo experiments was 7 months and 10 days, which reflected an improvement of 249%.

CONCLUSION

All methods posted in this study were evaluated to be effective to prolong the implantation lifetime of the puborectalis-like artificial anal sphincter. Among the methods proposed, the most effective was the addition of the outer shell to the puborectalis-like artificial anal sphincter. The least effective method was the improvement of the transmission structure. Medical titanium alloy and polyetheretherketone were good replacements for nylon-12 that managed to extend the implantation lifetime and yield a moderate improvement.

Toileting difficulties in older people with and without dementia receiving formal in-home care-A longitudinal study

AIM

To estimate the prevalence of toileting difficulties over time among older people (≥70 years) with and without dementia receiving formal in-home care at baseline and to explore whether dementia at baseline was associated with toileting difficulties at the last assessment when adjusting for relevant covariates. We hypothesize that those with dementia have a higher prevalence and that baseline dementia is associated with toileting difficulties at last follow-up.

DESIGN

A longitudinal observational study with three assessments over 36 months. Older people (≥70 years) from 19 Norwegian municipalities with in-home care needs were included. The participants and their next of kin were interviewed.

METHOD

In total, 1,001 (68% women) persons with a mean (SD) age 83.4 (5.7) years participated at baseline. Toileting difficulties were assessed using Lawton and Brody's Physical Self-Maintenance Scale and Individual Nursing and Care Statistics. Information on physical comorbidity, number of prescribed drugs, cognitive function and formal care given was included. Dementia was diagnosed based on all information gathered.

RESULTS

At all time points, toileting difficulties were more prevalent in people with than without dementia. In adjusted analyses, dementia at baseline was associated with toileting difficulties at the last assessment. Nursing home admission was associated with increased odds for toileting difficulties.

The Prevalence, Incidence, and Correlates of Fecal Incontinence Among Older People Residing in Care Homes: A Systematic Review

OBJECTIVE

Older people resident in care homes often rely on staff for support relating to their activities of daily living, including intimate care such as continence care. Managing fecal incontinence can be challenging for both residents and care staff. We conducted this review to describe the prevalence, incidence, and correlates of fecal incontinence among care home residents.

DESIGN

Systematic literature review.

SETTING AND PARTICIPANTS

Older care home residents (both nursing and residential care) aged 60 years and older.

MEASURES

We defined double incontinence as the presence of fecal plus urinary incontinence, isolated fecal incontinence as fecal incontinence with no urinary incontinence, and all fecal incontinence as anyone with fecal incontinence (whether isolated or double). The CINAHL and MEDLINE databases were searched up to December 31, 2017, to retrieve all studies reporting the prevalence and/or incidence and correlates of fecal incontinence.

RESULTS

We identified 278 citations after removing duplicates, and 23 articles met the inclusion criteria. There were 12 high-quality studies, 5 medium-quality studies, and 6 low-quality studies. The medians for prevalence (as reported by the studies) of isolated fecal incontinence, double incontinence, and all fecal incontinence were 3.5% [interquartile range (IQR) = 2.8%], 47.1% (IQR = 32.1%), and 42.8% (IQR = 21.1%), respectively. The most frequently reported correlates of fecal incontinence were cognitive impairment, limited functional capacity, urinary incontinence, reduced mobility, advanced age, and diarrhea.

CONCLUSIONS/IMPLICATIONS

Fecal incontinence is prevalent among older people living in care homes. Correlates included impaired ability to undertake activities of daily living, reduced mobility, laxative use, and altered stool consistency (eg, constipation or diarrhea) which are potentially amenable to interventions to improve fecal incontinence.

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.

Anatomy and mechanical properties of the anal sphincter muscles in healthy senior volunteers

BACKGROUND

A large proportion of age-related fecal incontinence is attributed to weakness or degeneration of the muscles composing the anal continence organ. However, the individual role of these muscles and their functional interplay remain poorly understood.

METHODS

This study employs a novel technique based on the combination of MR imaging and FLIP measurements (MR-FLIP) to obtain anatomical and mechanical information simultaneously. Unlike previous methods used to assess the mechanics of the continence organ, MR-FLIP allows inter-individual comparisons and statistical analysis of the sphincter morpho-mechanical parameters. The anatomy as well as voluntary and involuntary mechanical properties of the anal continence organ were characterized in 20 healthy senior volunteers.

RESULTS

Results showed that the external anal sphincter (EAS) forms a funnel-like shape with wall thickness increasing by a factor of 2.5 from distal (6 ± 0 mm) to proximal (15 ± 3 mm). Both voluntary and involuntary mechanical properties in this region correlate strongly with the thickness of the muscle. The positions of least compliance and maximal orifice closing were both located toward the proximal EAS end. In addition, maximal contraction during squeeze maneuvers was reached after 2 s, but high muscle fatigue was measured during a 7 s holding phase, corresponding to about 60% loss of the energy produced by the muscles during the contraction phase.

CONCLUSIONS

This work reports baseline parameters describing the morpho-mechanical condition of the sphincter muscle of healthy elderly volunteers. New parameters were also proposed to quantify the active properties of the muscles based on the mechanical energy associated with muscle contraction and fatigue. This information could be used to assess patients suffering from AI or for the design of novel implants.

A biomechanical model of the human defecatory system to investigate mechanisms of continence

This article presents a method to fabricate, measure and control a physical simulation of the human defecatory system to investigate individual and combined effects of anorectal angle and sphincter pressure on continence. To illustrate the capabilities and clinical relevance of the work, the influence of a passive-assistive artificial anal sphincter (FENIX^TM) is evaluated. A model rectum and associated soft tissues, based on geometry from an anonymised computed tomography dataset, was fabricated from silicone and showed behavioural realism to the biological system and ex vivo tissue. Simulated stool matter with similar rheological properties to human faeces was developed. Instrumentation and control hardware were used to regulate injection of simulated stool into the system, automate balloon catheter movement through the anal canal, define the anorectal angle and monitor stool flow rate, intra-rectal pressure, anal canal pressure and puborectalis force. Studies were conducted to examine the response of anorectal angles at 80°, 90° and 100° with simulated stool. Tests were then repeated with the inclusion of a FENIX device. Stool leakage was reduced as the anorectal angle became more acute. Conversely, intra-rectal pressure increased. Overall inclusion of the FENIX reduced faecal leakage, while combined effects of the FENIX and an acute anorectal angle showed the greatest resistance to faecal leakage. These data demonstrate that the anorectal angle and sphincter pressure are fundamental in maintaining continence. Furthermore, it demonstrates that use of the FENIX can increase resistance to faecal leakage and reduce anorectal angles required to maintain continence. Physical simulation of the defecatory system is an insightful tool to better understand, in a quantitative manner, the effects of the anorectal angle and sphincter pressure on continence. This work is valuable in helping improve our understanding of the physical behaviour of the continence mechanism and facilitating improved technologies to treat severe faecal incontinence.

The Role of Mental Health Disease in Potentially Preventable Hospitalizations: Findings From a Large State

BACKGROUND

Preventable hospitalizations are markers of potentially low-value care. Addressing the problem requires understanding their contributing factors.

OBJECTIVE

The objective of this study is to determine the correlation between specific mental health diseases and each potentially preventable hospitalization as defined by the Agency for Healthcare Research and Quality.

DESIGN/SUBJECTS

The Texas Inpatient Public Use Data File, an administrative database of all Texas hospital admissions, identified 7,351,476 adult acute care hospitalizations between 2005 and 2008.

MEASURES

A hierarchical multivariable logistic regression model clustered by admitting hospital adjusted for patient and hospital factors and admission date.

RESULTS

A total of 945,280 (12.9%) hospitalizations were potentially preventable, generating $6.3 billion in charges and 1.2 million hospital days per year. Mental health diseases [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.22-1.27] and substance use disorders (OR, 1.13; 95% CI, 1.12-1.13) both increased odds that a hospitalization was potentially preventable. However, each mental health disease varied from increasing or decreasing the odds of potentially preventable hospitalization depending on which of the 12 preventable hospitalization diagnoses were examined. Older age (OR, 3.69; 95% CI, 3.66-3.72 for age above 75 years compared with 18-44 y), black race (OR 1.44; 95% CI, 1.43-1.45 compared to white), being uninsured (OR 1.52; 95% CI, 1.51-1.54) or dual-eligible for both Medicare and Medicaid (OR, 1.23; 95% CI, 1.22-1.24) compared with privately insured, and living in a low-income area (OR, 1.20; 95% CI, 1.17-1.23 for lowest income quartile compared with highest) were other patient factors associated with potentially preventable hospitalizations.

CONCLUSIONS

Better coordination of preventative care for mental health disease may decrease potentially preventable hospitalizations.

Prevalence of fecal incontinence and associated risk factors in elderly outpatients: a cross-sectional study

BACKGROUND

Data on the prevalence of fecal incontinence in elderly patients admitted to outpatient clinics in Turkey are scarce.

AIMS

The aim of this study was to assess the prevalence of fecal incontinence and the associated risk factors in the elderly outpatients.

METHODS

Patients 60 years and older admitted to a geriatrics outpatient clinic between October 2013 and March 2014 were included. Demographic characteristics, anthropometric measurements, marital status, educational status, parity (for females), fecal incontinence (FI), urinary incontinence (UI), constipation, comorbid conditions, and medications were recorded. FI assessment was based on the Fecal Incontinence Severity Index (FISI).

RESULTS

A total of 364 patients (64.8% female, n = 236) with a mean age of 73.2 ± 8.1 years were enrolled in the study. The prevalence of FI was 9.9% (10.2% female, 9.4% male). UI was 42.6%. Co-occurrence of FI and UI was 7.4%. According to the FISI, the most frequent type of defecation was liquid stool (61.1%). While the predictive factors for FI were polypharmacy (standardized coefficient, [r] = 0.203, 95% confidence interval [CI] = 0.009-0.040, p = 0.002), UI (r = 0.134, 95% CI = 0.006-0.156, p = 0.035), and being married (r = 0.200, 95% CI = -0.088 to -0.020, p = 0.002) in females, those were UI (r = 0.306, 95% CI = 0.093-0.309, p < 0.001) and polypharmacy (r = 0.251, 95% CI = 0.009-0.043, p = 0.003) in males.

CONCLUSIONS

In both genders, urinary incontinence and polypharmacy seem to be the most important risk factors for fecal incontinence. Fecal incontinence should be questioned in detail and evaluated using FISI in elderly outpatients.

Exploring the concurrent validity of the nationwide assessment of permanent nursing home residence in Denmark - A cross-sectional data analysis using two administrative registries

BACKGROUND

Many register studies make use of information about permanent nursing home residents. Statistics Denmark (StatD) identifies nursing home residents by two different indirect methods, one based on reports from the municipalities regarding home care in taken place in a nursing home, and the other based on an algorithm created by StatD. The aim of the present study was to validate StatD's nursing home register using dedicated administrative municipality records on individual nursing home residents as gold standard.

METHODS

In total, ten Danish municipalities were selected. Within each Danish Region, we randomly selected one municipality reporting to Stat D (Method 1) and one not reporting where instead an algorithm created by StatD was used to discover nursing home residents (Method 2). Method 1 means that municipalities reported to Stat D whether home care has taken place in a nursing home or in a private home. Method 2 is based on an algorithm created by Stat D for the municipalities where Method 1 is not applicable. Our gold standard was the information from the local administrative system in all ten selected municipalities. Each municipality provided a list with all individuals > 65 years living in a nursing home on January 1st, 2013 as well as the central personal number. This was compared to the list of individuals >65 living in nursing home facilities in the same ten municipalities on January 1st, 2013 retrieved from StatD.

RESULTS

According to the data received directly from the municipalities, which was used as our gold Standard 3821 individuals were identified as nursing home residents. The StatD register identified 6,141 individuals as residents. Additionally, 556 of the individuals identified by the municipalities were not identified in the StatD register. Overall sensitivity for the ten municipalities in the StatD nursing home register was 0.85 (95% CI 0.84-0.87) and the PPV was 0.53 (95% CI 0.52-0.54). The municipalities for which nursing home status was based on the StatD algorithm (method 2) had a sensitivity of 0.84 (95% CI 0.82-0.86) and PPV of 0.48 (95% CI 0.46-0.50). Both slightly lower than the reporting municipalities (method 1) where the sensitivity was 0.87(95% CI 0.85-0.88) and the PPV was 0.57 (95% CI 0.56-0.59). Additionally, the sensitivity and PPV of the Stat D register varied heavily among the ten municipalities from 0.51 (95% CI 0.43-0.59) to 0.96 (95% CI 0.95-0.98) and PPV correspondingly, from 0.14 (95% CI: 0.11-0.17) to 0.73 (95% CI 0.69-0.77).

CONCLUSIONS

The overall PPV of StatD nursing home register was low and differences between municipalities existed. Even in countries with extensive nation-wide registers, validating studies should be conducted for outcomes based on these registers.

The effect of disability and depression on cognitive function and screening factors

INTRODUCTION

There is increasing evidence that subtle losses in cognitive function may be symptomatic of a transition to early dementia. The objectives of this study were to: 1) test the effect of depressive symptoms and/or disability on cognitive impairment, 2) explore the interaction between depression and disability and the association with cognitive impairment, and 3) evaluate risk factors of health assessment to discriminate between elderly people with or without cognitive impairment.

MATERIAL AND METHODS

The subjects were the community-dwellings aged 65 years and over who live in the sample city of southern Taiwan. 2734 persons were recruited by random sampling in the community, and the data was collected with face to face interviews by the training interviewers.

RESULTS

The effect of disability on cognitive impairment is stronger than the effect in depression. It also implies the possibility that disability may mediate the association between depression and cognitive impairment. Screening for risk factors of cognitive impairment was defined in this study and may be feasible for general population.

CONCLUSIONS

This study suggests that disability and depression assessments may serve as useful predictors of cognitive impairment. It is hoped that for elderly people, early assessment through screening factors could be arranged to this high-risk subgroup to reduce the risk of developing future dementia. Screening for functional disability and depressive symptoms would help to put management strategies in place that may reduce the associated cognition impairment burden.

Urinary Incontinence and Its Association with Frailty Among Men Aged 80 Years or Older in Taiwan: A Cross-Sectional Study

AIMS

To evaluate the prevalence of urinary incontinence (UI) and its association with frailty among men aged 80 years and older in Taiwan.

METHODS

Residents living in four veterans retirement communities were invited for study and 440 men aged 80 years and older were enrolled. Comprehensive geriatric assessment was performed for them, which composed of Clinical Frailty Scale, Northern Health and Social Care Trust (HSC)-Continence Assessment Form, Charlson's Comorbidity Index (CCI), Barthel Index (BI), Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Geriatric Depression Scale-5 (GDS-5), and Mini-Nutritional Assessment-Short Form (MNA-SF).

RESULTS

In this study, the overall prevalence of UI was 19.1% (mostly urgency incontinence and functional incontinence). Univariate analyses were performed to evaluate the associations between UI and other variables. Frailty was more common among subjects with UI than those without (60.7% vs 32.3%, p < 0.001). Besides, subjects with UI had more comorbidity (CCI: 1.40 ± 1.15 vs 0.89 ± 0.89, p < 0.001), poorer physical function (BI: 65.77 ± 33.39 vs 84.12 ± 24.08, p < 0.001; IADL: 3.46 ± 2.64 vs 4.41 ± 2.25, p = 0.003), more depressive symptoms (GDS-5: 1.83 ± 1.78 vs 1.18 ± 1.36, p = 0.02), poorer cognitive function (MMSE: 16.57 ± 7.65 vs 19.37 ± 6.82, p = 0.001), poorer nutritional status (MNA-SF: 10.0 ± 03.03 vs 11.23 ± 2.24, p = 0.001), more polypharmacy (66.7% vs 45.2%, p < 0.001) and higher chance of stool incontinence (22.6% vs 1.7%, p < 0.001). Multivariate logistic regression showed that UI was independently associated with frailty, (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.2-3.6; p = 0.012), stool incontinence (OR = 14.4; 95% CI 5.2-39.7; p < 0.001) and depressive symptoms (OR = 1.30; 95% CI 1.10-1.54; p = 0.002).

CONCLUSIONS

About one fifth of study subjects had UI (mostly urgency and functional incontinence type), which was significantly associated with frailty, stool incontinence and depressive symptoms. Further study is needed to evaluate the possibilities of reversing these geriatric syndromes by an integrated intervention program.

Artificial Muscle Devices: Innovations and Prospects for Fecal Incontinence Treatment

Fecal incontinence describes the involuntary loss of bowel content, which is responsible for stigmatization and social exclusion. It affects about 45% of retirement home residents and overall more than 12% of the adult population. Severe fecal incontinence can be treated by the implantation of an artificial sphincter. Currently available implants, however, are not part of everyday surgery due to long-term re-operation rates of 95% and definitive explantation rates of 40%. Such figures suggest that the implants fail to reproduce the capabilities of the natural sphincter. This article reviews the artificial sphincters on the market and under development, presents their physical principles of operation and critically analyzes their performance. We highlight the geometrical and mechanical parameters crucial for the design of an artificial fecal sphincter and propose more advanced mechanisms of action for a biomimetic device with sensory feedback. Dielectric electro-active polymer actuators are especially attractive because of their versatility, response time, reaction forces, and energy consumption. The availability of such technology will enable fast pressure adaption comparable to the natural feedback mechanism, so that tissue atrophy and erosion can be avoided while maintaining continence during daily activities.

Constipation and Laxative Use among Nursing Home Patients: Prevalence and Associations Derived from the Residents Assessment Instrument for Long-Term Care Facilities (interRAI LTCF)

Introduction. Constipation is a common, bothersome, and potentially dangerous condition among nursing home (NH) patients. Between 50 and 74% of NH patients use laxatives. Objective. To study prevalence and associations of laxative use and constipation using the comprehensive Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities. Methods. Cross-sectional study. Patients from 20 NH units were included. Logistic regression was used to analyze the results. Data collected in NHs might be clustered. Consequently, the multivariable models were tested against a mixed effects regression model to investigate variance both on the level of patients and on the level of NH units. Results. In all, 261 patients were included. The prevalence of constipation was 23.4%, and 67.1% used laxatives regularly. Balance problems, urinary incontinence, hypothyroidism, and Parkinson's disease were associated with constipation. Reduced ability to communicate and number of drugs were associated with laxative use. Antidementia-drugs and being involved in activities 1/3 to 2/3 of daytime were protective factors for laxative use. Mixed effects analyses identified variance on the level of NH units as nonsignificant. Conclusion. Constipation and laxative use are common. Variance is mainly explained by different patient characteristics/health deficiencies. Hence, patients might benefit from individualized care to compensate for deficiencies.

Change in Care Dependency and Nursing Care Problems in Nursing Home Residents with and without Dementia: A 2-Year Panel Study

Over time, chronic conditions like dementia can lead to care dependency and nursing care problems, often necessitating nursing home admission. This panel study (2012–2014) aims to explore changes in care dependency and nursing care problems (incontinence, malnutrition, decubitus, falls and restraints) in residents with and without dementia over time. In total, nine Austrian nursing homes participated, including 258 residents (178 with, 80 without dementia) who completed all five measurements. Data were collected with the International Prevalence Measurement of Care Problems questionnaire, the Care Dependency Scale and the Mini-Mental State Examination-2. Repeated measures ANOVA and crosstabs were used to analyse changes. The results showed that care dependency in dementia residents increased significantly for all 15 items of the Care Dependency Scale, with the highest increase being residents’ day-/night pattern, contact with others, sense of rules/values and communication. In contrast, care dependency in residents without dementia increased for four of the 15 items, with the highest increase being for continence, followed by getting (un)dressed. With respect to the assessed nursing care problems, residents with dementia and those without only differed significantly in terms of an increase in urinary- (12.3% vs. 14.2%), fecal- (17.4% vs. 10%), and double incontinence (16.7% vs. 11.9%). The results indicated that residents with dementia experienced increased care dependency in different areas than residents without dementia. Furthermore, residents with dementia experienced a lower increase in urinary incontinence but a higher increase in fecal- and double incontinence. These results help professionals to identify areas for improvement in dementia care.

Feasibility, acceptability, and adherence of two educational programs for care staff concerning nursing home patients' fecal incontinence: a pilot study preceding a cluster-randomized controlled trial

BACKGROUND

Fecal incontinence has a high prevalence in the nursing home population which cannot be explained by co-morbidity or anatomic and physiological changes of aging alone. Our hypothesis is that fecal incontinence can be prevented, cured, or ameliorated by offering care staff knowledge of best practice. However, it is not clear which educational model is most effective. To assess the effect of two educational programs for care staff, we planned a three armed cluster-randomized controlled trial. There is a lack of research reporting effects of interventions targeting improved continence care processes in older patients. Thus, to improve the quality of the planned trial, we decided to carry out a pilot study to investigate the feasibility of the planned design, the interventions (educational programs) and the outcome measures, and to enable a power calculation. This paper reports the results from the pilot study.

METHODS

Three nursing homes, representing each arm of the planned trial, were recruited. Criteria for assessing success of feasibility were pre-specified. Methods, outcome measures, acceptability, and adherence of the components of the intervention were evaluated by descriptive statistical analyses and qualitative content analysis of one focus group interview (n = 7) and four individual interviews.

RESULTS

The main study is feasible with one major and some minor modifications. Due to challenges with recruitment and indications supporting the assumption that a single intervention with one workshop is not sufficient as an implementation strategy, the main study will be reduced to two arms: a multifaceted education intervention and control. The components of the multifaceted intervention seemed to work well together and need only minor modification. Important barriers to consider were sub-optimal use of skill-mix, problems of communicating important assessments and care plans, and isolated nurses with an indistinct nurse identity.

CONCLUSIONS

Overall, the main study is feasible. The pedagogical approach needs to consider the identified barriers. Thus, it is essential to empower nurses in their professional role, to facilitate clinical reasoning and critical thinking among care staff, and to facilitate processes to enable care staff to find, report, and utilize information in the electronic patient record.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01939821.

Effect of a multifaceted educational program for care staff concerning fecal incontinence in nursing home patients: study protocol of a cluster randomized controlled trial

Background

Fecal incontinence has a high prevalence in the older population, which cannot be explained by comorbidity or the anatomical or psychological changes of aging alone. Fecal incontinence leads to a high economic burden to the healthcare system and is an important cause of institutionalization. In addition, fecal incontinence is associated with shame, social isolation and reduced quality of life. The importance of identifying treatable causes in the frail elderly is strongly emphasized. It is recommended that an assessment of fecal incontinence should be implemented as part of an evaluation of older patients. Although there is a substantial evidence base to guide choice of implementation activities targeting healthcare professionals, little implementation research has focused on the care of older people nor involved care processes or care personnel. This study is based on the assumption that fecal incontinence among nursing home patients can be prevented, cured or ameliorated by offering care staff knowledge of best practice through a multifaceted educational program. The primary objective is to test the hypothesis that a multifaceted educational program for nursing home care staff on assessment and treatment of fecal incontinence reduces patients’ frequency of fecal incontinence.

Methods/design

The study is a two-armed, parallel cluster-randomized controlled trial. Primary outcome is the frequency of fecal incontinence among patients. Sample size calculations resulted in a need for a total sample of 240 patients. Twenty nursing home units in one city in Norway will be recruited and allocated to intervention or control by an independent statistician using computer-generated tables. The intervention is a multifaceted educational program. Units in the control arm will provide care as usual. The intervention period is 3 months. Data will be collected at baseline, 3, and 6 months. Data will be analyzed using mixed effect models with the cluster treated as a random effect.

Discussion

This study is the first randomized controlled trial specifically focusing on this neglected area. The result of the study will give evidence for best practice for continence care in nursing homes, and organizational advice concerning implementation strategies.

Trial registration

ClinicalTrials.gov: NCT02183740, registered June 2014.

Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults

The objective of this work is to determine the prevalence of FI and associated factors in institutionalized elderly. A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes (NHs) of the city of Natal (Northeast Brazil). Individuals over the age of 60 were included in the study, while those hospitalized or in terminal phase were excluded. Data collection included sociodemographic information, FI 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). FI was verified through the Minimum Data Set (MDS) 3.0, which was also used to assess toileting programs. The Chi-square test and the linear Chi-square test were performed for bivariate analysis, as well as logistic regression for multivariate analysis. The final sample consisted of 321 elderly, mostly females, with mean age of 81.5 years. The prevalence of FI was 42.68% (CI 95%, 37.39-48.15). Most residents presenting FI were always incontinent (83.9%) and the most frequent incontinence type was total FI (solid and liquid stools). Incontinence control measures were applied only to 9.7% of the residents. The final model revealed a statistically significant association between FI and functional and cognitive impairments. It is concluded that FI is a health issue that affects almost half of the institutionalized elderly, and is associated with functional and cognitive disability.

Assessment of care problems in Romania: feasibility and exploration

OBJECTIVES

The objective of this study was to study the feasibility of a recently developed instrument, LPZ-International, which assesses care problems in health care, and to describe the prevalence of care problems in Romanian health care institutions. Large differences exist in care services in Europe. Data on quality of care are absent or incomplete in Central-Eastern European countries. These countries, including Romania, have faced dramatic socioeconomic changes, which led to negative changes in quality of care.

DESIGN

Cross-sectional study.

SETTING

Hospital wards, mental care institutions, and nursing homes.

PARTICIPANTS

Nine health care institutions and admitted 394 patients.

MEASURES

LPZ-International was introduced in 9 health care institutions in Romania. Assessed care problems included pressure ulcers, urinary and fecal incontinence, malnutrition, falls, and physical restraints. The data were collected between November 2013 and March 2014. Two health care professionals completed the questionnaire by hand at the patient's site.

RESULTS

Six of the 9 health care institutions and 90% of the patients participated, which indicates the feasibility of LPZ-International, as did the completeness of the questionnaire. The data showed a high consistency and only a few were missing. The most frequent care problem was urinary and fecal incontinence, especially in the nursing home. Pressure ulcers and malnutrition were less frequent care problems in Romanian patients. Physical restraints were frequently applied in the nursing home and geriatrics and oncology wards.

CONCLUSIONS

LPZ-International is a feasible instrument to assess care problems. The differences between wards and countries in the prevalence of care problems indicate differences in quality of care and the need for high-quality, comparative research.

Bowel problem management among nursing home residents: a mixed methods study

Background

Bowel problems such as constipation, diarrhoea and faecal incontinence (FI) are prevalent conditions among nursing home residents and little is known about nursing management. This study aimed to elucidate how Norwegian registered nurses (RNs) manage bowel problems among nursing home residents.

Methods

A mixed methods approach was used combining quantitative data from a population-based cross-sectional survey and qualitative data from a focus group interview. In the cross sectional part of the study 27 of 28 nursing homes in one Norwegian municipality participated. Residents were included if they, at the time of data collection, had been a resident in a nursing home for more than three weeks or had prior stays of more than four weeks during the last six months. Residents were excluded from the study if they were younger than 65 years or had a stoma (N = 980 after exclusions). RNs filled in a questionnaire for residents regarding FI, constipation, diarrhoea, and treatments/interventions. In the focus group interview, 8 RNs participated. The focus group interview used an interview guide that included six open-ended questions.

Results

Pad use (88.9%) and fixed toilet schedules (38.6%) were the most commonly used interventions for residents with FI. In addition, the qualitative data showed that controlled emptying of the bowels with laxatives and/or enemas was common. Common interventions for residents with constipation were laxatives (66.2%) and enemas (47%), dietary interventions (7.3%) and manual emptying of feces (6.3%). In addition, the qualitative data showed that the RNs also used fixed toilet schedules for residents with constipation. Interventions for residents with diarrhoea were Loperamide (18.3%) and dietary interventions (20.1%). RNs described bowel care management as challenging due to limited time and resources. Consequently, compromises were a part of their working strategies.

Conclusions

Constipation was considered to be the main focus of bowel management. Emptying the residents’ bowels was the aim of nursing intervention. FI was mainly treated passively with pads and interventions for residents with diarrhoea were limited. The RNs prioritized routine tasks in the nursing homes due to limited resources, and thereby compromising with the resident’s need for individualized bowel care.

What characteristics predispose to continence in nursing home residents?: a population-based cross-sectional study

Aims

To compare characteristics of both continent and incontinent residents in Nursing Homes (NHs) and to explore what predicts continence and severity of incontinence.

Methods

A population-based cross-sectional study was performed in nursing homes in one Norwegian municipality. Registered nurses filled in a questionnaire on behalf of the patients.

Results

We found that 25.4% of the NH residents were continent, 31.8% had urinary incontinence alone, 2.6% had fecal incontinence alone and 40.2% had double incontinence. Continent residents were characterized by being in short-term care, shorter stay in NH, less cognitive and physical impairment, less Parkinson's disease, stroke, constipation, and less diarrhea and more independence in activities of daily living (ADL). Residents with fecal incontinence alone were characterized by more diarrhea, less cognitive impairment and less dependency in ADL such as feeding and grooming. Residents with urinary incontinence alone were characterized by having some degree of ADL dependency, less diarrhea, and less diabetes. Residents with double incontinence were characterized by being in long-term care, a longer length of stay in NH, cognitive impairment, stroke, constipation, diarrhea, and dependency in ADL. Severity of incontinence was associated with dependency in ADL and cognitive impairment, diarrhea, length of stay in NH and lower age.

Conclusions

About 25% of NH residents were continent. Double incontinence and urinary incontinence only were prevalent conditions in NHs, while FI alone was rarer. With the exception of diarrhea as a cause of FI, it appears that FI alone, UI alone, and DI may have common causes and development. Neurourol. Urodynam. 34:362–367, 2015. © 2014 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.