Continence Care Options for the Long-Term Care Resident: A Supplement to the Journal of the American Medical Directors Association

Abstract

Urinary incontinence is a common and important clinical problem in long-term care. The subject deserves treatment as a supplement to the Journal of the American Medical Directors Association, the flagship journal for our organization. It is important to primary care physicians involved in long-term care geriatrics as a part of continuity of primary care and for what may be an emerging medical specialty in long-term care geriatrics. In developing this supplement, I have been joined by Karen Prochoda, MD, CMD, an experienced medical director, to discuss the scope of the problem, costs of urinary incontinence, and the impact on residents’ quality of life and to elaborate on regulatory issues. I will provide a basic science foundation of relevant issues in anatomy, physiology, and pharmacology on which the reader may build an understanding of the rationale for the diagnostic process and for treatment. Thomas Lackner, PharmD, CGP, FASCP, will review available data from refereed sources regarding pharmacotherapy for various subtypes of urinary incontinence. Finally, Theodore Johnson, MD, MPH, CMD, will discuss behavioral treatment of urinary incontinence, surgical approaches, incontinence devices, and incontinence garments. He will also enlighten us on appropriate and inappropriate use of urinary catheters and on the assessment of patient preferences in developing a plan for treatment of urinary incontinence. I have recently publicly been somewhat critical of other industry-sponsored journal supplements for continuing medical education. Therefore, I have been specially attuned to avoiding unidentified bias within this supplement. The reader will, however, be aware that the authors of this supplement admit to a slightly more aggressive approach to the management of urinary incontinence with pharmacotherapy or for combined therapy in the long-term care resident than is implied in Agency for Health Care Policy and Research (AHCPR) or American Medical Directors Association (AMDA) clinical practice guidelines. Although this might be attributed to our relationships with the pharmaceutical industry, our clinical reasoning to the contrary is included in the text. The purpose of this supplement is not to replace AHCPR guidelines or AMDA clinical practice guidelines for urinary incontinence but instead to build on these to broaden the reader’s understanding of the subject in light of recent developments in both science and regulation. At times the authors will depart from the aforementioned guidelines, explaining reasons and circumstances for those departures. This is a clear example why guidelines should not be considered as dogmatic, authoritative statements for purposes of survey or litigation. Guidelines are general standards to consider during the process of development of an individualized plan of care for an individual patient/resident. In fact, AMDA guidelines purport to significantly depart from AHCPR guidelines for these same reasons, because care of urinary incontinence in the long-term care setting is significantly different from that in the overall population. The authors offer these potential departures from other guidelines for consideration in appropriate clinical circumstances and caregiving settings. I wish to thank the other authors for their skill and cooperation and the editorial board of Journal of the American Medical Directors Association for the opportunity to coordinate this supplement. I also wish to thank Ortho McNeill for their support through an unrestricted educational grant and the readership for your interest and commitment to the quality of care for the frail elderly.