Incontinence In Older Patients Research Articles

8 Improving Identification and Assessment of Urinary Incontinence in Older People

Abstract Introduction Urinary incontinence is very common in the older people and wrongly considered a normal part of aging. The prevalence of UI is 39.1% in people with frailty and 19.4% in those without (Veronese et al. European Geriatric Medicine, 2018, 9(5), 571–578). Despite the high prevalence of urinary incontinence, its detection and management remain suboptimal. A comprehensive multidisciplinary continence assessment is recommended to assess and manage urinary incontinence in older patients (NICE CG171). Methods Plan, Do, Study, Act (PDSA) cycle audit was conducted to identify the practices for identification and assessment of urinary incontinence on a care of elderly ward. Data was collected on a structured proforma containing six standards prospectively. Following the results of first cycle, a strategy was developed and implemented. Results Strategy Cycle 1 (35 patients) results were disseminated to the Divisional Safety and Quality Committee, ward teams, educational sessions held for multidisciplinary teams, involved Trust's continence advisor, displayed multidisciplinary teams prompt sheets, trialled new nursing documentation booklet, discussed continence status at daily board round and conducted audit cycle 2 (28 patients) after 4 months. Conclusions PDSA cycle audit with involvement of multidisciplinary teams, presentation to the Divisional Quality and Safety Committee combined with regular educational sessions and prompt about continence status at the daily board round led to better detection and improved management of urinary incontinence. We recommend other clinical teams to follow our strategy to improve the urinary incontinence care in older people without any additional resource.

Managing urinary incontinence in older people in hospital: a best practice implementation project.

This project aimed to improve care in managing urinary incontinence in older patients admitted to a medium-to-long-stay hospital by developing and implementing strategies to improve the compliance with best practice in managing urinary incontinence and decrease its prevalence. Urinary incontinence (UI) is a major problem in hospitalized older people and is of great significance to public health. The application of evidence-based recommendations for this problem could be expected to improve the quality of care. The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in healthcare practice. Participants were evaluated at baseline and at two follow-ups at three and six months after key strategies had been implemented. The location of this implementation project was the functional rehabilitation ward of a medium-to-long-stay Spanish hospital. In baseline audit there were four process criteria with a high level of compliance: two criteria with 35% and 44% respectively and one criterion without compliance. Action was taken to address the four barriers identified, leading to an increase in all cases except one, which was related to the characteristics of the patient. Prevalence of urinary incontinence decreased at follow-up. The development and implementation of strategies improved quality of care. This project obtained positive results in patient health, and the implementation of the strategies used decreased the prevalence of urinary incontinence in patients.

Long-term follow-up of bulking agents for stress urinary incontinence in older patients.

Implantation of bulking agents represents a noninvasive procedure for the treatment of stress urinary incontinence (SUI) in all patients where a more invasive procedure may increase perioperative risks. The primary aim of this retrospective study was to evaluate the efficacy over time of bulking agent implantation. As secondary aims, we evaluated long-term (patients' subjective) satisfaction rate, rate of de novo urinary symptoms, and the impact of urinary incontinence on the quality of life. All patients who underwent implantation of bulking agents between 1999 and 2013 at Campus Bio-Medico of Rome were retrospectively considered eligible for this study. Patients were interviewed using two standardized questionnaires: International Consultation on Incontinence Questionnaire Short Form and Patient Global Impression of Improvement. Cure rate, improvement rate, failure rate, and the onset of new symptoms were also investigated through specific questions. The original group of patients was then divided into two subgroups according to follow-up time (group A: shorter than median follow-up; group B: longer than median follow-up). Sixty-three patients were enrolled. Mean follow-up was 8.3 ± 3.5 years with a range of 3.5 to 18 years. Fifteen (24%) cured patients (cure rate), 12 (19%) improved patients (improvement rate), 36 (57%) failed treatment (failure rate). We reported an overall success rate of 43%. No differences were reported among groups in terms of overall success rate (42% vs 44% for group A and group B, respectively). Bulking agent implantation is an effective treatment for people with intrinsic sphincter deficiency (type III SUI) and it is a valid alternative to more invasive surgeries in older patients. Moreover, it shows an overall success rate (43%) that remains high even after many years.

Fecal Incontinence in Older Patients. A Narrative Review

Fecal incontinence is one of the leading causes for the institutionalization of people in the last decades of life, associated with a great psychosocial and economic burden. The literature is scarce in this population group, due to the absence of universally accepted criteria to define “elderly patients” and difficulties in detection and diagnostic. The aim of this article was to conduct a narrative review of the main aspects related to fecal incontinence in older patients, providing management support. Toileting assistance, dietary change, controlling stool consistency and medical treatment can be used to treat these patients. Nevertheless, other therapies, such as biofeedback, neuromodulation or surgical treatment, can be considered in selected patients.

Incontinencia fecal en el paciente anciano. Revisión de conjunto

Fecal incontinence is one of the leading causes for the institutionalization of people in the last decades of life, associated with a great psychosocial and economic burden. The literature is scarce in this population group, due to the absence of universally accepted criteria to define “elderly patients” and difficulties in detection and diagnostic. The aim of this article was to conduct a narrative review of the main aspects related to fecal incontinence in older patients, providing management support. Toileting assistance, dietary change, controlling stool consistency and medical treatment can be used to treat these patients. Nevertheless, other therapies, such as biofeedback, neuromodulation or surgical treatment, can be considered in selected patients.

Voiding dysfunction in older men.

Voiding dysfunction in older men is an important health issue, with significant morbidity and biosocioeconomic burden. Treatment decisions are increasingly complex as many older men also suffer concurrent comorbidities and polypharmacy. A relatively sparse number of publications specifically examine this relevant topic. Common geriatric voiding syndromes include overactive bladder (OAB) and underactive bladder, with nocturia and incontinence often the most bothersome lower urinary tract symptoms, and may represent a falls risk together with OAB and incontinence. The combination of detrusor overactivity and impaired contractility may coexist in older patients and can be particularly difficult to diagnose and treat clinically. A small but not insignificant proportion of older men experience spontaneous remission of OAB symptoms without treatment, and 'watchful waiting' may be a reasonable option. OAB treatment with mirabegron may have a preferable side-effect profile compared with anticholinergics in older men. Intravesical onabotulinum toxin A is effective but risk of retention is greater in the older adults. Benign prostatic obstruction (BPO) and underactive bladder may lead to urinary retention, necessitating surgery or catheterization. BPO surgery is a reasonable option in older men, with realistic counselling of postoperative expectations. Combination BPO surgery and medical OAB treatment is suitable for detrusor overactivity and impaired contractility. Stress incontinence in older patients is usually iatrogenic and treatment can include continence applicances, urethral bulking agents, suburethral sling or artificial urinary sphincter. Management of voiding dysfunction in older patients need to take into account multiple factors including symptomatic and functional impairment, cognition, comorbidities and polypharmacy. Future research examining pathophysiology and treatment outcomes of voiding dysfunction in the older patient population is increasingly relevant.

Inkontinenz

Urinary incontinence is a common health problem of older adults and affects more than 50% of nursing home residents. Different types of urinary incontinence can be distinguished: urgency, stress, overflow (urinary retention) and extra-urethral incontinence. The pathogenesis of urinary incontinence in older patients is multifactorial. Age-related physiologic changes, urological or gynaecological ailments, neurological diseases, behavioural patterns and functional decline frequently contribute to incontinence to some extent. These pathogenetic factors may appear in close relation to frailty. As incontinence on the one hand may substantially contribute to decompensation of health reserves, and on the other hand is an indicator for frailty, early assessment and treatment are important. Clinical diagnostics focus on history, physical examination, bladder diary and measurement of postvoid residual volume. Diagnostic and therapeutic approaches to urinary incontinence should focus on finding and treating reversible causes. Behavioural interventions such as toileting procedures may reduce the level of incontinence even in severe cases. Frail older adults with functional decline and urgency incontinence often do not respond well to drug treatment. Paramount for the adequate care for incontinent seniors is the instruction of the affected person and--if necessary--of their caregiver in handling incontinence aids.

Functional Incidental Training: A Randomized, Controlled, Crossover Trial in Veterans Affairs Nursing Homes

To test the effects of a rehabilitative intervention directed at continence, mobility, endurance, and strength (Functional Incidental Training (FIT)) in older patients in Department of Veterans Affairs (VA) nursing homes. Randomized, controlled, crossover trial. Four VA nursing homes. All 528 patients in the nursing homes were screened; 178 were eligible, and 107 were randomized to an immediate intervention group (Group 1; n=52) and a delayed intervention group (Group 2; n=55). Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength-training exercises offered four times per day, 5 days per week, for 8 weeks. Group 1 received the intervention while Group 2 served as a control group; then Group 2 received the intervention while Group 1 crossed over to no intervention. A total of 64 subjects completed the intervention phase of the trial. Timed measures of walking or wheeling a wheelchair (mobility), sit-to-stand exercises, independence in locomotion and toileting as assessed using the Functional Independence Measure (FIM), one-repetition maximum weight for several measures of upper and lower body strength, frequency of urine and stool incontinence, and appropriate toileting ratios. There was a significant effect of the FIT intervention on virtually all measures of endurance, strength, and urinary incontinence but not on the FIM for locomotion or toileting. The effects of FIT were observed when Group 1 received the intervention and was compared with the control group and when Group 2 crossed over to the intervention. Group 1 deteriorated in all measures during the 8-week crossover period. Within-person comparisons also demonstrated significant effects on all measures in the 64 participants who completed the intervention; 43 (67%) of these participants were "responders" based on maintenance or improvement in at least one measure of endurance, strength, and urinary incontinence. No adverse events related to FIT occurred during the study period. FIT improves endurance, strength, and urinary incontinence in older patients residing in VA nursing homes. Translating these positive benefits achieved under research conditions into practice will be challenging because of the implications of the intervention for staff workload and thereby the costs of care.

Fecal Incontinence in Older Patients

Fecal incontinence (FI), the involuntary passage of fecal material through the anus, is a common medical problem in older people, especially in frail older nursing home residents. FI is often associated with urinary incontinence. Severe constipation leading to fecal impaction, laxative abuse, diarrhea, cognitive impairment, senescence, and neuromuscular disorders including autonomic neuropathy, are among the leading causes of FI in older patients. FI affects patients' physical and psychological well-being, and is responsible for considerable morbidity and mortality in older patients. This results in significant healthcare costs. Comprehensive management of this disorder requires a systematic approach including thorough history, physical examination, and step-wise evaluation. This review in contrast to others published in last decade,^1–9 focuses on management of FI in frail older nursing home patients, who require an individualized approach, which should be minimally invasive and cost-effective. In many cases of FI, treatment of the underlying condition; adequate control of diarrhea, constipation, or fecal impaction; adjustment of medications; and proper feeding may control or reduce FI. Advanced tests are often not necessary in this population.