Behavioral management of urinary incontinence in homebound older adults

Cognitive components of behavioral therapy for overactive bladder: a systematic review

INTRODUCTION AND HYPOTHESIS

Behavioral therapy is the first-line treatment for overactive bladder (OAB); however, the cognitive components of behavioral therapy for OAB have not been evaluated. The purposes of this systematic review were to describe the cognitive components of behavioral therapy for OAB and evaluate their effectiveness as well as to describe their rationale and origins.

METHODS

Searches were conducted on the PubMed, CINAHL, Web of Science, Cochrane and PEDro databases. Inclusion criteria were single-arm or randomized controlled trials on OAB treatment that utilized behavioral therapy, with a description of a cognitive component of the behavioral therapy. Study participants were neurologically intact adults (n = 1169). Study methodological quality was assessed with the PEDro and Newcastle-Ottawa scales.

RESULTS

Five studies were included, published between 2009 and 2020. Methodological quality was variable. All studies reported a reduction of symptoms in participants receiving behavioral therapy. Cognitive components of behavioral therapy were not extensively described. Distraction was the most common cognitive strategy for managing urgency. The relative impact of the cognitive aspect of behavioral therapy could not be evaluated, and the cognitive aspects of behavioral therapy appear to be accepted wisdom, traceable to several key authors, that has not been subjected to scientific investigation.

CONCLUSIONS

Behavioral therapy for OAB appears useful, but its cognitive components are not well described, their relative importance has not been evaluated or ascertained, nor have they been rigorously studied.

Design of programs to train pelvic floor muscles in men with urinary dysfunction: Systematic review

AIMS

Pelvic floor muscle training (PFMT) is a first line conservative treatment for men with urinary dysfunction, but reports of its efficacy are variable. This study aimed to systematically review the content of PFMT programs used for urinary dysfunction in men.

METHODS

Electronic databases (PubMed, CINAHL, EMBASE, Cochrane, PEDro) were searched for studies that used PFMT in the treatment of adult men with urinary dysfunction. Details of PFMT treatment sessions and home exercise protocols were extracted. Criteria specific to PFMT were developed, based on the Consensus on Exercise Reporting Template, and applied to all studies to measure the comprehensiveness of the PFMT description in the manuscript.

RESULTS

Results from the 108 included studies indicate substantial heterogeneity in both the content of PFMT and the quality of reporting of the components of the exercise regimes. There was notable disparity in the muscles targeted by the interventions (and few focused on urethral control despite the use in management of urinary conditions) and the intensity of the programs (eg, 18-240 contractions per day). Most studies were missing key details of description of the PFMT programs (eg, the position in which the pelvic floor muscle [PFM] contraction was taught and how it was assessed, methods used to ensure exercise adherence).

CONCLUSIONS

Variation in content of PFMT programs is likely to contribute to variation in the reported efficacy for management of urinary dysfunction in men, and unclear description of the details of the evaluated programs makes it difficult to identify the effective/ineffective components. PROSPERO registration number CRD42017071038.

Structured behavioral treatment research protocol for women with mixed urinary incontinence and overactive bladder symptoms

AIMS

The primary aim is to provide detailed rationale and methodology for the development and implementation of a perioperative behavioral/pelvic floor exercise research protocol for women who self-chose surgical intervention and who may or may not have been offered behavioral treatments initially. This protocol is part of the ESTEEM trial (Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence Trial) which was designed to determine the effect of a combined surgical and perioperative behavioral/pelvic floor exercise intervention versus surgery alone on improving mixed urinary incontinence (MUI) and overactive bladder (OAB) symptoms.

METHODS

As part of a multi-site, prospective, randomized trial of women with MUI electing midurethral sling (MUS) surgical treatment, participants were randomized to a standardized perioperative behavioral/pelvic floor exercise intervention + MUS versus MUS alone. The specific behavioral intervention included: education on voiding habits, pelvic floor muscle training (PFMT), bladder training (BT), strategies to control urgency and reduce/prevent urinary symptoms, and monitoring/promoting adherence to behavioral recommendations. To ensure consistency across all eight research sites in the pelvic floor disorders network (PFDN), selective behavioral treatments sessions were audiotaped and audited for protocol adherence.

RESULTS

The behavioral intervention protocol includes individualization of interventions using an algorithm based on pelvic floor muscle (PFM) assessment, participant symptoms, and findings from the study visits. We present, here, the specific perioperative behavioral/pelvic floor exercise interventions administered by study interventionists.

CONCLUSIONS

This paper details a perioperative behavioral/pelvic floor exercise intervention research study protocol developed for women undergoing surgery for MUI.

Nursing management of urinary incontinence associated with Alzheimer's disease

"Incontinence in the patient with Alzheimer's disease is a multifaceted and complex problem." This article provides information on the management of incontinence through assessment and education of families. Included are causes of incontinence, instructions on toileting, and suggestions for supportive measures when the patient loses the ability to respond to verbal requests. This information will be helpful to many patients receiving home health care services.

Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care

Background

Urinary incontinence (UI) following acute stroke is common, affecting between 40% and 60% of people in hospital, but is often poorly managed.

Aim

To develop, implement and evaluate the preliminary effectiveness and potential cost-effectiveness of a systematic voiding programme (SVP), with or without supported implementation, for the management of UI after stroke in secondary care.

Design

Structured in line with the Medical Research Council framework for the evaluation of complex interventions, the programme comprised two phases: Phase I, evidence synthesis of combined approaches to manage UI post stroke, case study of the introduction of the SVP in one stroke service; Phase II, cluster randomised controlled exploratory trial incorporating a process evaluation and testing of health economic data collection methods.

Setting

One English stroke service (case study) and 12 stroke services in England and Wales (randomised trial).

Participants

Case study, 43 patients; randomised trial, 413 patients admitted to hospital with stroke and UI.

Interventions

A SVP comprising assessment, individualised conservative interventions and weekly review. In the supported implementation trial arm, facilitation was used as an implementation strategy to support and enable people to change their practice.

Main outcome measures

Participant incontinence (presence/absence) at 12 weeks post stroke. Secondary outcomes were quality of life, frequency and severity of incontinence, urinary symptoms, activities of daily living and death, at discharge, 6, 12 and 52 weeks post stroke.

Results

There was no suggestion of a beneficial effect on outcome at 12 weeks post stroke [intervention vs. usual care: odds ratio (OR) 1.02, 95% confidence interval (CI) 0.54 to 1.93; supported implementation vs. usual care: OR 1.06, 95% CI 0.54 to 2.09]. There was weak evidence of better outcomes on the Incontinence Impact Questionnaire in supported implementation (OR 1.22, 95% CI 0.72 to 2.08) but the CI is wide and includes both clinically relevant benefit and harm. Both intervention arms had a higher estimated odds of continence for patients with urge incontinence than usual care (intervention: OR 1.58, 95% CI 0.83 to 2.99; supported implementation: OR 1.73, 95% CI 0.88 to 3.43). The process evaluation showed that the SVP increased the visibility of continence management through greater evaluation of patients’ trajectories and outcomes, and closer attention to workload. In-hospital resource use had to be based on estimates provided by staff. The response rates for the postal questionnaires were 73% and 56% of eligible patients at 12 and 52 weeks respectively. Completion of individual data items varied between 67% and 100%.

Conclusions

The trial was exploratory and did not set out to establish effectiveness; however, there are indications the intervention may be effective in patients with urge and stress incontinence. A definitive trial is now warranted.

Study registration

This study is registered as ISRCTN08609907.

Funding details

The National Institute for Health Research Programme Grants for Applied Research programme. Excess treatment costs and research support costs were funded by participating NHS trusts and health boards, Lancashire and Cumbria and East Anglia Comprehensive Local Research Networks and the Welsh National Institute for Social Care and Health Research.

Adult urinary incontinence: Assessment, intervention, and the role of clinical health psychology in program development

Urinary incontinence (UI) is a disorder receiving little attention from clinical health psychologists. This paper establishes the importance of addressing the issue of UI within the clinical and research practices of clinical health psychologists. Over 10 million Americans suffer from loss of bladder control. Incontinence affects over half of older individuals in long-term care institutions, about one-third of hospitalized elderly, and up to 30% of Americans over the age of 60 living at home. Because of social stigma and misconceptions attached to urinary incontinence, it is estimated that less than half of those affected see a physician about their condition. Since UI is generally associated with medical, social, psychological, and economic consequences, a multidisciplinary perspective is important because these factors are integral in the selection of appropriate treatment. Definitions of UI, its incidence and costs, and brief reviews of treatment and management techniques are presented. Psychological sequelae and treatments are presented as a foundation for developing further treatment and research approaches. Guidelines for collaboration and consultation by clinical health psychologists with medical professionals in the area of UI are also discussed.

State of the science: conservative interventions for urinary incontinence in frail community-dwelling older adults

This systematic literature review aimed to identify conservative interventions for reducing urinary incontinence (UI) in non-institutionalized frail older adults. Randomized and quasi-experimental studies published in English reporting outcomes on UI frequency, severity, or quality of life were included and rated for quality. Studies reporting improvements over 50% in UI outcomes were considered clinically significant. Seven studies with 683 participants (75% female) were eligible. Multicomponent behavioral interventions including pelvic floor muscle exercises and bladder training had the strongest evidence for reducing UI. The evidence supporting comprehensive geriatric assessment with multicomponent behavioral interventions, pattern urge response training, and toilet skills was limited. There is insufficient evidence to derive firm conclusions regarding the use of conservative interventions. Clinical trials are needed on a variety of interventions to guide practice on UI prevention and management in frail community-dwelling older adults.

Effectiveness of educational interventions to raise men's awareness of bladder and bowel health

BACKGROUND

Urinary incontinence is a common health problem with significant medical, psychological and economic burdens. Health education is capable of improving perceptions about and attitudes towards incontinence in turn encouraging them to seek help.

AIM

The aim of the present study was to determine the effectiveness of educational interventions at raising men's awareness of bladder and bowel health.

INCLUSION CRITERIA

Types of participants. Adult and adolescent men (age 12 years and over) and it was anticipated that some interventions/promotions may be directed at family members or carers of, and health professionals caring for, adult men and therefore these would also be considered for inclusion. Types of intervention. Any intervention, program or action that provided information, or attempted to raise awareness of men's bladder and bowel health. Type of outcome. Any measure defined by included studies such as: bladder and bowel management and treatment, increased knowledge of bladder and bowel health and number of attendees at promotion. Type of studies. Concurrent controls, such as: systematic reviews of concurrently controlled trials, meta-analysis, randomised controlled trials, controlled clinical trials, interrupted time series and controlled before after designs and observational design (cohort, case-control). Search strategy. A search for published and unpublished studies in the English language was undertaken restricted by a publication date of 10 years prior, with the exception of a review of seminal papers before this time.

METHODOLOGICAL QUALITY

Each study was appraised independently by two reviewers using the standard Joanna Briggs Institute instruments.

DATA COLLECTION AND ANALYSIS

Information was extracted from studies meeting quality criteria using the standard Joanna Briggs Institute tools. For two studies with similar population types, interventions and outcomes quantitative results were combined into a meta-analysis using Revman 5.0 software. However, the majority of studies were heterogenous and results are presented in a narrative form.

RESULTS

With the exception of instruction for pelvic floor muscle exercises for men after prostatectomy, little quantitative research has been performed that establishes the effectiveness of interventions on men's awareness of bladder and bowel health. While numerous interventions have been trialled on mixed gender populations, and these trials suggest that the interventions would be effective, their effectiveness on the male component cannot be definitively established.

CONCLUSION

There is little quantitative evidence for the effectiveness of interventions to improve men's awareness of bladder and bowel health therefore few recommendations can be made. Well-designed controlled trials using male sample populations only are needed.

9 myths of incontinence in older adults: both clinicians and the over-65 set need to know more

Despite progress made in the research into and treatment of urinary incontinence, its incidence is rising among older adults. Many reasons for this disturbing finding have been posed: clinicians' insufficient knowledge of urinary incontinence, the reluctance of patients to discuss it, and inadequately individualized care. Common misconceptions of bladder health in older adults are explored to address these concerns and help prepare nurses in all settings to provide care that prevents and treats incontinence.

Future directions for incontinence research with frail elders

BACKGROUND

The most vulnerable older adults are often referred to as the frail elderly. There is a high prevalence of urinary incontinence (UI) in this population, yet there is little research to guide nurses in providing effective continence care to this vulnerable group of elders.

OBJECTIVES

To summarize current knowledge on UI in frail older adults and suggest future areas for research in this population.

METHODS

Existing literature about UI in the frail elderly was analyzed to generate a plan for future research.

RESULTS

Gaps exist in the knowledge base needed to guide the nursing care of incontinent frail elders in the following areas: effectiveness of interventions, caregiver characteristics and management models, prevalence, risk factors, and reliability and validity of outcome measures. There are barriers to conducting research in long-term care settings.

CONCLUSIONS

Despite the challenges inherent in doing research with incontinent frail elders, there is an urgent need for research to guide the nursing care of this population in all healthcare settings.

Protocol- and therapist-related variables affecting outcomes of behavioral interventions for urinary and fecal incontinence

Biofeedback techniques used to treat urinary and fecal incontinence lack standardization. Most early protocols used a pressure device placed within the vagina or anal canal, or electromyographic (EMG) sensors in the same locations, to measure the external anal sphincter (EAS) or pelvic floor muscle (PFM) contractile function, and most early studies provided feedback from a single physiological transducer. The goal was to improve bowel and bladder control by improving EAS or PFM contractile function. Protocols that have resulted in the most consistent reductions in urinary incontinent episodes used 2 or more channels of physiological information to reinforce stable abdominal and bladder pressures concurrently with PFM contraction. For fecal incontinence, more significant treatment results were derived when protocols measured (1) patient perception of sensory cues associated with rectal distention and potential loss of stool, (2) short-latency EAS contraction when perceiving rectal distention, (3) inhibition of (extraneous muscle) activity that would increase intra-abdominal pressure during EAS contraction, and (4) reinforcement of sustained (up to 30 seconds) contractions rather than only brief 1- to 2-second contractions. Limited data support the use of surface abdominal EMG measures as indices of extraneous muscle activity associated with increased intra-abdominal pressure and anal or vaginal EMG probes to obtain measures of PFM function. Better results may also be obtained when there are at least 4 training sessions, when daily home exercises are prescribed, and when the therapist is well trained and experienced. These inferences are based for the most part on indirect evidence, and more studies are needed that compare different treatment protocols.

Predictors of treatment response to behavioral therapy and pharmacotherapy for urinary incontinence

Demographic, medical, and physiologic predictors of behavioral treatment and pharmacotherapy success would be useful in selecting treatments for specific patients with urinary incontinence based on their histories, physical examinations, and urodynamic profiles. The author performed a systematic review of clinical trials of behavioral treatment or pharmacotherapy for urinary incontinence. Most postulated predictors (age, type and duration of incontinence, medications including diuretics and estrogen, obstetric history, physical examination, and urodynamic findings) were not predictive of treatment outcomes. For behavioral therapy, male gender predicted worse outcomes in 1 study, but it was not a predictor in 2 other studies. Greater severity of incontinence predicted positive outcomes in 2 studies, negative outcomes in 3 studies, and had no predictive value in 5 studies. Prior treatment for incontinence predicted poorer outcomes in 2 studies of urge incontinence but was not predictive in a study of stress incontinence. Prior surgical treatment predicted better outcomes in 1 study of urge incontinence in women but was unrelated in 4 studies. Male gender, depression, or the use of assistive devices for ambulation predicted poorer outcomes in homebound older persons. For pharmacotherapy of urge incontinence, older age, female gender, and greater incontinence severity were associated with poorer outcomes in 1 study. Age was unassociated with outcomes in another study. Thus, the literature on predictors of outcomes of behavioral and drug treatment for urinary incontinence is inconsistent and does not provide guidelines for treatment selection. More studies, with large samples, that use multivariate regression analysis to examine predictors of outcomes are needed.

A randomized trial of behavioral management for continence with older rural women

Urinary incontinence (UI) is a commonly underreported and underdiagnosed condition. The purpose of this trial was to implement and evaluate behavioral management for continence (BMC), an intervention to manage symptoms of UI with older rural women in their homes. Participants were randomized into BMC or a control group, and 178 were followed for between 6 and 24 months. The intervention involved self-monitoring, bladder training, and pelvic muscle exercise with biofeedback. The primary outcome variable-severity of urine loss-was evaluated by pad test. Secondary variables were episodes of urine loss, micturition frequency, voiding interval, quality of life, and subjective report of severity. Urine loss severity at baseline evaluation was not significantly different in the two groups. But using the generalized linear mixed model analysis, at the four follow-ups, severity of urine loss, episodes of urine loss, quality of life, and subjective report of severity were significantly different. At 2 years the BMC group UI severity decreased by 61%; the control group severity increased by 184%. Self-monitoring and bladder training accounted for most of the improvement. The results support the use of simple strategies based on bladder diaries before implementing more complex treatments.

Effectiveness of behavioral therapy to treat incontinence in homebound older adults

OBJECTIVES

To examine the (1) short-term effectiveness of behavioral therapies in homebound older adults and (2) characteristics of responders and nonresponders to the therapies.

DESIGN

Prospective, controlled clinical trial with cross-over design.

SETTING

Adults aged 60 and older with urinary incontinence and who met Health Care Financing Administration criteria for being homebound were referred to the study by homecare nurses from two large Medicare-approved home health agencies in a large metropolitan county in southwestern Pennsylvania.

MEASURES

Structured continence and medical history, OARS Physical and Instrumental Activities of Daily Living scales, Folstein Mini-Mental State Examination Score, Clock Drawing Test, Geriatric Depression Scale, Performance-Based Toileting Assessment, bladder diaries, and physical examination.

RESULTS

One hundred five subjects were randomized to biofeedback-assisted pelvic floor muscle training (53 to the treatment group and 52 to the control groups). Control subjects with complete pre- and post-control data (n = 45) experienced a median 6.4% reduction in urinary accidents in contrast to a median 75.0% reduction in subjects with complete pre- and post-treatment data (n = 48, P < .001). Following the control phase, subjects crossed over to the treatment protocol. Eighty-five subjects completed treatment, achieving a median 73.9% reduction in UI. Exercise adherence was the most consistent predictor of responsiveness to the behavioral therapy.

CONCLUSIONS

Clinically significant reductions in urinary incontinence are achievable with behavioral therapies in many cognitively intact homebound older adults despite high levels of co-morbidity and functional impairment.

Characteristics of urinary incontinence in homebound older adults

OBJECTIVE

To describe the characteristics of urinary incontinence and related factors in incontinent homebound older adults.

DESIGN

A descriptive study of 90 cognitively intact incontinent homebound older persons referred to a clinical trial to examine the effectiveness of behavioral therapies in the treatment of urinary incontinence (UI) in homebound patients.

SETTING AND PARTICIPANTS

Incontinent patients more than 60 years of age who met the Health Care Financing Administration's definition of homebound were referred to a clinical trial by home care nurses from a Medicare-approved home care agency in a large metropolitan country in Pennsylvania.

MEASURES

Structured continence and medical history, basic and instrumental activities of daily living, Folstein MMSE, Geriatric Depression Scale, mobility-toileting skills, bladder diaries, and physical examination.

RESULTS

Four hundred eighty-four persons were referred to the clinical trial, and 90 cognitively intact persons were found eligible to participate in this study (80 women and 10 men). Subjects had a mean age of 75.8 years, reported a mean of 8.4 medical problems, and most, 80%, had functional limitations in ambulation. Subjects recorded a mean of 3.8 urinary accidents/day-1.4 large and 2.4 small accidents/ day-in baseline bladder diaries. The majority, 73.3%, had more than 10 accidents per week, and most patients reported mixed urge, stress (57.1%), or pure urge (37.7%) UI. Half (54.4%) reported that UI further restricted their activities, and 52.2% reported that this problem was extremely disturbing. However, 90.5% believed that UI could be treated.

CONCLUSIONS

Urinary incontinence tends to be severe among cognitively intact homebound older adults in both frequency and volume of accidents. Although subjects were homebound with many health and functional disabilities, they perceived UI as a very disturbing problem that further restricted their activities. Participants in this study were optimistic about the potential benefits of treatment.

Treatment with the Reliance urinary control insert: one-year experience

The 1-year experience of 63 women using an intraurethral insert for the management of stress or mild mixed urinary incontinence is presented, emphasizing safety and efficacy. Objective criteria, including standardized pad weight tests and patient diaries, were employed to evaluate the device's effectiveness. At study outset, 82% of the patients were completely dry with the device in situ, with an additional 16% of patients significantly improved. At 12 months, 79% of the patients were completely dry, and 16% were significantly improved. This result is consistent with the significant improvement (P < 0.0001) in the number of urinary incontinence episodes reported in patient diaries. Women reported that the device significantly improved their ability to stay dry over a number of routine and physically demanding daily activities. The device was increasingly easy to use and more comfortable over time (P < 0.0001). The latter finding was confirmed by a decline in patient reports of "sensation of device presence" over the duration of the study (35% at 1 week v 7% at 12 months). Untoward events included gross hematuria (24%), device-related bladder mucosal irritation (9%), and symptomatic bacteriuria (30%). Such side effects were expected for this type of device, were easily managed without significant medical intervention, and did not result in any long-term clinical sequelae. The great reduction in the number of episodes of urinary incontinence, the low rate of significant problems associated with device use, and ease of use make the intraurethral insert a useful management alternative for women with stress urinary incontinence.

Urinary incontinence management in the USA: the role of the nurse

Urinary incontinence (UI) is a prevalent medical problem in the USA. Approximately 12 million Americans are incontinent of urine. Hu et al (1994) estimate that the costs of managing the problem are $10 billion annually. In persons aged 65 years and older the incidence of UI is 30% or more it is estimated that more than 60% of people with UI never mention their problem to a doctor of nurse. This is a sad fact considering that UI is a highly treatable, if not curable, problem. In the USA, advanced practice nurses, nurse practitioners and clinical nurse specialists who have advanced educational and master's degrees and clinical practice requirements are making a significant impact on the management of UI. This article outlines the role of advanced practice nurses in the diagnosis and behavioural management of UI.

Effectiveness of pelvic muscle exercises in reducing urge incontinence among community residing elders

1. Urinary incontinence is a costly and prevalent problem, affecting 15% to 39% of all community residing elders. 2. Some elders suffering from urge incontinence prefer pelvic muscle exercises to bladder training as the behavioral intervention of choice. 3. Although pelvic muscle exercises are frequently associated as an intervention for stress incontinence, they have been found to be effective in significantly reducing urge incontinence. 4. Nurses are in a key position to identify and treat urinary incontinence among the elderly, and should incorporate continence restoration interventions into their practice.

Pelvic muscle exercise for stress urinary incontinence in elderly women

PURPOSE

To compare pelvic muscle exercise to pharmacologic treatment of stress urinary incontinence, the most common cause of urine leakage reported by community-living elderly women.

SUBJECTS

Convenience sample of 157 community-living women, aged 55 to 90 years, after completion of a comprehensive diagnostic evaluation.

METHODS

Eighty-two subjects were randomly assigned to the exercise protocol (with a 34% attrition rate). Pelvic muscle exercises were taught and monitored for 6 months. Phenylpropanolamine hydrochloride was given to the other group in a dose of 50 mg a day, increasing to 50 mg twice a day.

MAIN RESULTS

Treatment outcomes (subjective improvement, self recorded frequency of wetting) were equally satisfactory in both groups. The response to exercises was as good in 5 months as in 6. It was also as good when the minimum recommended number of exercises per day was 80 as when it was 125.

CONCLUSIONS

Among those completing the protocol, pelvic exercises were beneficial in reducing stress incontinence, and the benefit was comparable to that produced by phenylpropanolamine.