Helping Residents Stay Dry

AN INTERVIEW WITH MARY H. PALMER, PHD

Are there any recent research findings regarding urinary incontinence that might be of interest to our readers and might help them provide better care?
Dr. Palmer: Some researchers have combined toileting with a low-intensity exercise program as a method to care for nursing home residents who suffer from incontinence (Schnelle JF, Kapur K, Alessi C, et al. J Am Geriatr Soc 2003;51:161-8). The reasoning is that if caregivers can help residents retain their mobility and function through exercise, thereby enabling them to reach the toilet in time, it might maintain or improve their continence level. The researchers found this approach more effective than a toileting program alone in terms of improving residents’ strength, mobility, endurance, and urinary and fecal incontinence. The study sought to show cost savings from this approach. While that outcome was not shown, the researchers concluded that there were clear advantages in terms of quality of life.

If you were establishing an incontinence-management program in a long-term care facility, what components would you consider indispensable?
Dr. Palmer: First, it is extremely important that there be a true buy-in from the organization’s administration. The program has to be valued by upper levels and spread throughout the organization. Many times we expect frontline staff, the CNAs, to take a program and run with it, but then administration neither asks how it’s going nor promotes its value. Therefore, the program can lose momentum.

The message should be that incontinence is an important issue in our facility, and that the program and measures put in place to deal with it are important, as well. In fact, more importantly, if you can change the organization’s culture so that instead of thinking in terms of incontinence, staff and administration are thinking in terms of continence, the next step will be to ask how you can change the environment to reflect that value. Thinking in those terms might reveal new, effective strategies.

Another component of a successful program is that everyone must understand the program’s goals. They must be realistic, so that no one is disappointed by false expectations. Sometimes we can’t get residents 100% dry, and sometimes they won’t become dry on behavioral interventions alone. Staff need to have input regarding what will and won’t work, and family members should be considered part of the care team, too.

What makes for a successful toileting program?
Dr. Palmer: Toileting schedules have to be individualized, based on resident assessments. Assessment should include factors that cause transient/reversible incontinence (such as urinary tract infection, urinary retention, dehydration, delirium, restricted mobility, atrophic vaginitis, urethritis, fecal impaction, and polypharmacy). A bladder record should be kept to help determine the type and frequency of incontinence. The RAP (Resident Assessment Profile) provides guidance in terms of the baseline evaluation of incontinence in nursing homes.

In addition to this assessment, a physical examination, a detailed assessment of the genitourinary system, functional assessment, and evaluation of environmental barriers (such as changes in living conditions, clothing, location of toilet, and/or nighttime access to toilet) need to be performed.

A toileting schedule of every two hours has been commonly used, but that might not be appropriate for all residents; and given staff-to-resident ratios, that schedule is difficult to maintain. Some residents can, in fact, do quite well on a schedule of every 3 or 4 hours.

Prompted voiding is most successful in the more cognitively intact residents who can recognize their need to void. According to Lyons and Specht (Lyons SS, Specht JK. J Gerontol Nurs 2000;26:5-13), other good indicators that prompted voiding will be successful are that the resident generally voids four or fewer times during the day, appropriately uses the toilet more than 66% of the time during the first three days of prompted voiding, voids in toileting receptacles at least 50% of the time on the first day of prompted voiding, can void successfully when given toileting assistance, can ambulate independently, has a maximum voided volume of more than 1,500 cc, and has a residual after voiding less than 100 cc.

In addition to these behavioral programs, are there any medications for treating incontinence that you consider useful in the nursing home setting?
Dr. Palmer: There are some pharmacologic treatments for urge incontinence, such as a muscle relaxant for the bladder, but there are none yet for stress incontinence. However, contraindications exist for the use of these agents in the geriatric population. The old adage “start low and go slow” certainly would apply here, but we should keep in mind that not a lot of research with these drugs has been conducted in this population.

For residents who have been diagnosed with urge incontinence and who can tolerate medications with anticholinergic effects, there are medications that may be helpful, such as tolterodine and oxy-butynin. These drugs can cause dry mouth, blurred vision, constipation, and mental status changes, however. A tricyclic antidepressant, imipramine, has also been used for urge incontinence. It can cause postural hypotension, cardiac arrhythmia, weakness, and fatigue. Both oxybutynin and imipramine can increase intraocular pressure. Because of these drugs’ associated side effects, careful review of the person’s medical history, assessment of baseline function prior to administering medication, and monitoring of the person’s reaction to medication are essential.

In your view, what are the most common mistakes long-term care facilities make in their programs to manage urinary incontinence?
Dr. Palmer: I think the biggest mistake is treating all the residents alike, such as using a blanket toileting schedule. We must remember that some residents are more capable of self-care than others. Some might be able to use female urinals or other external collecting devices, which would enable them to retain some degree of independence. When not given such opportunities, residents end up becoming more incontinent than they really need to be. As I said earlier, some residents won’t get drier with prompted voiding. You must have an individualized care plan based on an assessment.

A mistake that some residents make-and we should watch for this-is to stop drinking fluids in an attempt to avoid accidents. Just the opposite result can occur; without enough fluid, the bladder can become irritated, and low-volume voiding can occur.

Are there any specific evaluation tools or methods for assessing residents with urinary incontinence that you consider particularly useful?
Dr. Palmer: I think the most useful tool is a bladder diary, or record. Facilities can create their own to use for residents. These diaries don’t need to be used indefinitely; five to seven days is adequate. They can be used for identifying the times of day that an individual is continent or incontinent, when he or she voids, how many fluids he/she ingests, and when. This enables you to see voiding patterns, which can help to prevent incontinence episodes. Once you identify when a given resident will most likely need to urinate, you can plan strategies: e.g., making sure the resident has access to a toilet or bedside commode at that time, or perhaps making a bedpan available before the resident leaves bed in the morning.

What do you consider to be the most successful measures to help residents overcome urinary incontinence?
Dr. Palmer: Prompted voiding has been researched the most, but as I said before, it’s probably most appropriate for those residents who aren’t very incontinent and who can go to the bathroom without assistance or who will cooperate with toileting. When a caregiver approaches residents for toileting, they should request to use the toilet. You want them to get to the point where they realize what’s happening in their bodies-whether their bladders are full or not. And you want them to empty their bladders completely in an appropriate place.

What are some other methods to help residents remain continent?
Dr. Palmer: There are some promising new technologies and devices, such as female urinals, external collection devices, and a wristwatch with a discreet beep that reminds the wearer to use the toilet. As I mentioned earlier, helping people improve their mobility has been shown to be beneficial, as are good signage to direct people to bathrooms and the use of simple reminders-e.g., before a visit to the beauty parlor or activities room, etc.

You should also monitor bowel function, because minimizing constipation can also help bladder function. Also, older women should be checked for atrophic vaginitis-and treated if they have it. For women who do not have a medical history that would contraindicate estrogen use, low-dose topical estrogen cream for a short-term course may be helpful in alleviating atrophic vaginitis. This can improve urge incontinence in some women.

Another useful tool for caregivers is the new supplement to the American Journal of Nursing that came out in March, on the state of the science on urinary incontinence. The supplement, which includes an article on incontinence in the frail elderly and will be especially useful for long-term care nurses, is available free online. It can be downloaded from NursingCenter.com/UI. Also, 6.5 CE credits are available in association with the supplement. NH