Enhanced continence care

Resident incontinence represents a major challenge for the long-term care (LTC) industry. It negatively impacts residents on many levels and has a significant economic impact on the service provider both in terms of the support care required and direct-expense costs. The Canadian Continence Foundation has estimated that the cost of a senior with incontinence living in a Canadian LTC facility can average $3,000 to $10,000 per year for supplies and related nursing care.

Urinary incontinence (UI) is defined as the complaint of any involuntary leakage of urine. In LTC facilities, more than 50% of persons experience UI either occasionally or on a regular basis and many would argue the rate is even higher. UI is a contributing factor to skin breakdown, falls, urinary tract infections, social isolation, frustration, anxiety, calling out, and wandering.

Recent research by Earthy into the advantages of routine toileting has shown that maintaining a “normal” toileting pattern, in a sitting position and in a private space, contributes to improved resident self-esteem and dignity. Determining resident voiding and bowel patterns and having staff assist them to the bathroom according to each resident’s natural schedule is sometimes seen by staff as too time-consuming. However, a time analysis performed by an independent body to compare the time it took to cleanse residents on the control unit to caring for the residents on the research unit who were assisted to the bathroom (with or without mechanical devices) suggested that it took only 2.01 minutes longer to toilet a person and return him or her to a chair or bed than it did to cleanse the person in bed. In addition, there were financial savings of over $30,000 annually for the 75-bed unit related to decreased use of linens, briefs, and medications. With a focused approach that included interdisciplinary staff and residents’ education, bladder scanning, and encouragement of a “normal” toileting pattern, the study showed that, in just one year, the percentage of residents toileted regularly to void rose from 12% to 67% in the research group. This is a remarkable difference that resulted in statistically significant gains in appetite, sleep, self-care, and in decreased calling out and wandering.

A United Kingdom paper, Health Care of Older People Program (2005), concluded that there is a missed opportunity to assess, treat, and reduce the number of persons experiencing incontinence, because there tends to be more emphasis on containment rather than cure. This is expensive, from both a financial and health perspective. Instead, more attention needs to be directed to promoting and maintaining continence abilities and preventing avoidable bowel and urinary continence decline. Staff education is required to disseminate research findings that demonstrate that incontinence is not a normal part of aging and that continence can often be maintained when the team works together to maintain residents’ lifelong elimination patterns.

Encouraging normal voiding patterns is clearly essential for improved continence, but there are other ways a facility can help encourage more residents to maintain and even regain the ability to self-toilet. Treatment of functional incontinence depends on the successful management of causative or contributing conditions. Several key physical factors including mobility, transfer ability, strength, and flexibility are essential for independent toileting. Targeting these abilities for improvement, then, is crucial in any effort to increase the number of individuals who can self-toilet.

Innovative mobility training tools provide LTC facilities with the capacity to effectively improve residents’ ability to sit, stand, transfer, and walk. A key by-product of improved standing and mobility is the ability to manage toileting more independently. One such device (figure 1) is designed to help residents who cannot stand regain the ability to stand independently. Actively assisting the standing motion with support at the knee, trunk, and arms to promote early mobility, the Sit-to-Stand Trainer uses a counterweight mechanism to provide a safe and effective way to strengthen weight-bearing muscles and increase standing stability and endurance. Unlike other tools that lift people to or maintain them in a standing position, this equipment enables a resident to successfully initiate the motion of standing up, even with weakened or seemingly unsuccessful efforts. Through regular training (typically a few minutes 3 to 4 times per week) and gradually reducing the counterweight, a resident can relearn the standing up skill and redevelop the strength and confidence necessary to do so more independently.

For residents who are able to stand but lack the strength, balance, and confidence to walk, a body-weight bungee support tool enables motor retraining (figure 2). It provides safe ways to practice balance, walking, and natural protective side-steps, by counteracting loss of stability with graduated support from beneath. This allows residents to safely begin to walk and work on balance skills without being held up by an overhead harness that doesn’t allow natural responses, and hence useful practice, in loss-of-balance situations.

Regaining and maintaining mobility and balance skills at a level that allows safe, independent toileting requires practice. Many LTC facilities are incorporating Nintendo Wii biofeedback systems like the Wii Fit into their rehab and activity programs to make mobility exercises more enjoyable. Another versatile and powerful biofeedback device is the NeuroGym Trainer that helps the resident to regain balance, coordination, and motor control. By using input from various sensors to control the action of computer games, residents receive real-time, speed-sensitive feedback about their balance and movement skills. They can, for example, play a video game of pong or guide a car along a track by shifting their weight from side to side while standing on pressure-sensing foot plates.

Electromyographic (EMG) biofeedback is currently one of the most successful treatment techniques for urinary incontinence. The Trainer can also use this type of muscle input via a vaginal sensor to retrain weak or ineffective pelvic floor muscles with speed-sensitive video game biofeedback.

Incontinence need not be accepted as an inevitable, ever-increasing expense in LTC facilities. By educating staff and scheduling for more routine toileting, as well as implementing more robust mobility training programs, elderly residents can achieve higher levels of continence.

Anne Earthy, BN, MA, GNC(C), is a CNS in Gerontology, presently Clinical Lead for Vancouver Community: Residential, Vancouver Coastal Health Authority, British Columbia, Canada. Avinoam Nativ, PhD, PT, is President of NeuroGym Rehabilitation and Founder of Technologies, Inc., Ottawa, Ontario, Canada. NeuroGym Technologies, Inc. manufactures a unique line of mobility training equipment that can significantly improve functional independence.

For more information, call (877) 523-4148, e-mail sales@neurogymtech.com, or visit www.neurogymtech.com. To send your comments to the authors and editors, e-mail earthy0309@iadvanceseniorcare.com.

Long-Term Living 2009 March;58(3):24-25

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