Continence Care for Frail Older Adults: It is Time to Go Beyond Assessing Quality

Abstract

Readers of JAMDA should not be surprised by the findings on the quality of care provided to incontinent older adults reported in this month’s issue. After all, we have known for decades that a majority of older adults with urinary incontinence do not report it to their primary care physician, and that the evaluation and management of this condition are less than optimal. The situation is even worse for the close to one million incontinent older adults living in nursing homes, among whom the most common method of management is adult diapers. Worse yet, many older people are continent when they enter a nursing home, are placed in diapers, and told to urinate in them when they request toileting assistance, a demeaning form of iatrogenic incontinence. Would you like your relatives or patients treated this way? How can this situation be changed? The “ACOVE” project is a noble effort to improve the care of vulnerable older adults. Absent a large body of data from randomized, controlled trials, the ACOVE project team has critically reviewed what literature does exist, and developed quality indicators for important geriatric conditions based on these data and a careful and systematic expert opinion process. Quality indicators are now available for outpatient, inpatient, and nursing home settings. The study reported in this issue of JAMDA is a follow up to a paper that describes overall adherence to the outpatient ACOVE indicators using a sample of 372 patients who met the vulnerability criteria and for whom medical records were available in two large health maintenance organizations (HMOs). HMOs could or could not be the optimal setting to study adherence to these indicators. On the one hand, HMOs are focused on preventive care, and one would think that these organizations would strive to identify and treat geriatric conditions such as incontinence that could result in considerable morbidity and cost such as falls and related injuries among older women with urge incontinence. On the other hand, identifying otherwise unrecognized incontinence could result in additional expenditures for the HMO resulting from diagnostic tests and treatments (including some surgical interventions). Moreover, if the incontinence contributes to nursing home admission, HMOs are generally not responsible for these costs and thus have no financial incentive to prevent such admissions. Irrespective of the nature and size of the population studied (only 32 patients receiving outpatient care with new or worsened incontinence form the basis of the data reported in this issue), it is still astounding that only 20% of the incontinent women had a pelvic examination documented, less than half of the men had a rectal examination documented, and only 38% had a urinalysis and 16% had a postvoid residual (PVR) determination. The latter is somewhat understandable, because without a portable ultrasound device, a PVR requires a catheterization and could in fact be unnecessary in many patients with clearcut symptoms and no risk factors for urinary retention. Yet, over 50% of these patients were treated with drugs, apparently without much of a diagnostic evaluation. Of even more relevance to readers of JAMDA, several studies have documented that a similar state of affairs exists in nursing homes. Over 20 years ago, one of the authors (JGO) documented, using a brief and superficially developed audit tool, that the vast majority of over 400 incontinent residents of seven nursing homes in Los Angeles had no documentation of any diagnostic evaluation or treatment for their incontinence. A much more recent, systematic, and extensive study in several hundred incontinent residents of 52 nursing homes in upstate New York revealed a “failing grade,” as judged by 90 standards of practice derived from the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline. Although this guideline was not specifically designed for nursing home residents, the majority of the 90 standards studied are embodied in the AMDA incontinence practice guideline. Another very recent study using an audit tool and interviews based on the ACOVE nursing home quality indicators for incontinence in 426 residents of 18 California nursing homes demonstrated a similar failing grade, and reDivision of Geriatric Medicine and Gerontology, Department of Medicine, Emory University, Emory Center for Health in Aging, Birmingham/Atlanta VA GRECC (J.G.O.); and the Division of Geriatric Medicine and Gerontology, Department of Medicine, Emory University, Geriatrics and Extended Care Service Line, Veterans Integrated Service Network 7, Geriatrics and Extended Care Service Line, Atlanta VA Medical Center, Birmingham/Atlanta GRECC (T.M.J.).