Role of functional assessment in the evaluation of urinary incontinence

Comparison between elderly inpatient fallers with and without dementia

INTRODUCTION

This study aimed to examine the various factors associated with inpatient falls among patients with and without dementia in a hospital setting.

METHODS

This was a retrospective one-year study using data collected from Singapore General Hospital's electronic reporting system for inpatient falls.

RESULTS

In the study period, 298 patients aged ≥ 65 years fell during their hospital stay. The majority of the patients (n = 248) did not have dementia. In our study, fallers with dementia were more likely to use ambulatory aids, be visually impaired and have urinary incontinence. More patients with dementia than those without had a history of previous falls, and were placed on fall precaution with restricted freedom of movement, which at times, included restraints. However, the difference between patients who were put on restraints and those who were allowed to move freely was not statistically significant. The majority of falls in both groups occurred at the bedside. We found that fallers without dementia were more likely to fall during the morning shift, whereas fallers with dementia were more likely to fall during the night shift. Fallers with dementia were more likely to be confused at the time of the fall.

CONCLUSION

In our study, we found that fallers with dementia were more likely to have visual impairment, have urinary incontinence, use walking aids, and to be confused and physically restrained at the time of the fall. The fallers without dementia in our study may have undiagnosed dementia.

Geriatric assessment and management protocols: issues for home infusion therapy providers

The accurate assessment of patients' health, functional abilities, and sociobehavioral status is essential for providing quality, cost-effective infusion services to home-based elders. Baseline and ongoing assessment identifies serious current, emerging, and potential problems, and facilitates interventions to prevent significant comorbidities and premature mortality. Three types of assessment (screening, intermediate or evaluation, and comprehensive) have been used successfully with geriatric populations across a variety of settings to improve patient outcomes. Further, Medicare now requires the completion of an OASIS assessment for the reimbursement of home health services to all seniors. Geriatric assessment has been found to improve care quality and cost effectiveness, but protocol development and evaluation can be challenging. Home infusion therapy providers, encouraged to implement and evaluate evidence-based assessment and management protocols, question the usefulness of these protocols, especially for short-term geriatric patients. Research, education, and policy strategies can be used to overcome the many barriers to developing quality, cost-effective assessment and management protocols for elderly home infusion therapy recipients.

Classifying the probability of urinary incontinence in psychogeriatric nursing home patients

Urinary incontinence (UI) frequently occurs in psychogeriatric nursing home patients. In general the personnel involved in the care for these patients act on incontinence noted. Patients are not monitored or classified according to likelihood or severity of incontinence. This study was conducted to develop and validate a model for the classification of the likelihood of UI in demented nursing home patients. A multi-center cross-sectional study was conducted using data on clinical and functional status of 692 subjects. Subjects were subdivided in a Derivation set of 532 patients and a Validation set of 160 patients. The data were ascertained with questionnaires completed by physicians and nursing staff. All psychogeriatric wards (25) of four Dutch nursing homes were included. Using univariate logistic regression analysis on the derivation set we identified correlates of UI among 22 clinical and functional patient characteristics. Subsequently, we developed a classification model for prevalent UI, including independent patient characteristics by means of multivariable logistic regression. Next, we stratified patients into groups with varying likelihood's of UI based on the model developed. Subsequently, we transformed the model to an easy applicable classification rule for the identification of patient subgroups with high or low likelihood on UI. Finally, the rule was validated on the validation set. The independent multivariate factors associated with urinary incontinence were impaired ADL and mobility, diminished alertness and fecal impaction. After transforming the regression model to an easy classification rule, the scores ranged from 0 to 7. The area under the curve was 0.88 (95% Confidence Interval (CI): 0.85-0.91) in the derivation set. In the validation set a similar area under the curve was obtained (0.90 (95% CI: 0.85-0.95)). Among subjects with none of the associated factors the rule classified 0.5% as incontinent patients. In case all associated factors were present the proportion classified as incontinent increased to 91%. In conclusion, the developed classification rule provides means to stratifying nursing home patients according to their likelihood of being incontinent of urine.

Predicting success using individualized scheduled toileting for memory-impaired elders at home

The purpose of this research was to evaluate the effectiveness of an individualized scheduled toileting (IST) program on incontinent, memory-impaired elders being cared for at home. Using a 2 x 2 mixed design analysis of variance (group by time), 118 patients were randomly assigned to experimental or control groups. Caregivers in the experimental group were taught the IST procedure. Urinary incontinence (UI) was measured at baseline and at 6 months. Weeklong voiding records were kept by caregivers and were used to calculate the percentage of times the incontinence occurred. UI significantly decreased in the experimental group, whereas in the control group it did not. The baseline cognitive ability, mobility, and consistency of implementing IST were entered into a discriminant function equation and significantly predicted patients who would improve with IST. Cognitive ability was the best predictor, with mobility also emerging as a meaningful predictor. Candidates for IST should be selected based on elders' cognitive ability and their ability to cooperate with toileting. Moderately cognitively impaired elders and ones able to cooperate with toileting protocols are prime candidates for IST.

The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set

OBJECTIVES

To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population.

DESIGN

Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS.

SETTING

270 Medicaid-certified nursing homes in 10 states.

PARTICIPANTS

A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size.

MEASUREMENTS

Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints).

RESULTS

Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04).

CONCLUSIONS

Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.

Urinary incontinence in the elderly population

OBJECTIVE

To describe the causes, evaluation, and management of urinary incontinence in the elderly population.

DESIGN

We reviewed pertinent articles in the medical literature and summarized the types of incontinence and contributing factors.

RESULTS

Urinary incontinence is common in elderly patients and often has a major role in determining whether a person can remain independent in the community or requires nursing home placement. Urinary incontinence is not a single entity but rather several different conditions, each with specific symptoms, findings on examination, and recommended treatment. Thus, accurate classification is important for appropriate management. Because of the complexity of urinary incontinence, many physicians are uncomfortable with undertaking assessment and treatment. Hence, many patients are not asked about incontinence, and the condition remains untreated and often considered a natural consequence of the aging process. Urinary incontinence can be treated and either cured or alleviated with treatment.

CONCLUSION

Elderly patients should be asked about symptoms of urinary incontinence because appropriate assessment and treatment can usually provide relief.

Urinary incontinence associated with dementia

Urinary incontinence is common in patients with dementia and is more prevalent in demented than in nondemented older individuals. It occurs with equal or greater frequency in males than in females, and this contrasts with the female preponderance in community-based, general older populations. Since the etiology of incontinence in dementia is multifactorial, a comprehensive assessment of factors within and outside the lower urinary tract is essential. A careful clinical evaluation is sufficient to guide treatment in most cases. Further research is needed to determine the role of simple cystometry and more complex urodynamic investigation in these patients. Research on the management of urinary incontinence in demented patients has focused almost exclusively on toileting programs and drug treatments for detrusor hyperactivity. To date, anticholinergic and antispasmodic medications have not been shown to be effective in treating incontinence in demented persons. However, the few studies undertaken have been in the most severely mentally and physically deteriorated patients, and it is possible that these medications have greater efficacy in less impaired individuals. Prompted voiding regimens have been shown to reduce incontinence by an average of 32% and appear to be a useful approach in managing incontinence in some of these patients. However, unless staff management systems are employed, staff compliance with these programs diminishes with time and the labor costs involved may limit their applicability in nursing homes. Patients who are the most severely cognitively impaired, least mobile, and have the greatest frequency of incontinence derive the least benefit from toileting programs, and palliative measures may be more appropriate in these cases.

Behavioral management for bladder control: response in selected rural residential care homes

Urinary incontinence is a problem for elders in many settings, including rural residential care homes (RCHs). Behavioral techniques for the management of urinary incontinence have been successful with community-dwelling and nursing home populations. A study was undertaken to evaluate the feasibility of implementing bladder diaries and bladder training to assist RCH residents with bladder control. These techniques were found not to be successful in selected rural RCHs. The characteristics of rural RCHs are explored, and the impediments and incentives to the use of behavioral management techniques for urinary incontinence in these settings are examined.

A health-promotion perspective of urinary continence

The purposes of this article are to discuss continence in older adults from a public health perspective, to expand a previously reported conceptual model of continence health promotion, and to provide a primary prevention focus to nursing research efforts regarding continence. The conceptual model shows that there has been a strong interest in secondary and tertiary prevention strategies, but little interest in primary prevention. Use of the matrix allows the nurse researcher identify primary, secondary, or tertiary prevention research questions and the target population for study. Historically, nurses have had a central role in the care and management of incontinent people. Nurses will continue to play a critical role in the evolution of research-based practice that includes identification of risks, health promotion, and preventive nursing strategies.