Identification and intervention for urinary incontinence by community physicians and geriatric assessment teams

Management of urinary incontinence in females by primary care providers: a systematic review

OBJECTIVE

To describe primary care provider (PCP) practices for the assessment and management of females with urinary incontinence (UI), and appraise these practices relative to recommendations made in high-quality clinical guidelines.

METHODS

Studies were searched in four databases (MEDLINE, EMBASE, CINAHL, Web of Science) from their respective inception dates to 6 March 2023. All studies describing UI evaluation and management practices used by PCPs for female patients were eligible. Two reviewers independently selected studies assessed their quality and extracted data. A narrative synthesis of included studies was performed to describe practices. Relevant evaluation and management practices were then compared to recommendations that were consistent across current high-quality UI guidelines. Pharmacotherapy, referrals, and follow-ups were reported descriptively only.

RESULTS

A total of 3475 articles were retrieved and, among those, 31 were included in the review. The majority reported a poor-moderate adherence to performing a pelvic examination (reported adherence range: 23-76%; based on eight studies), abdominal examination (0-87%; three studies), pelvic floor muscle assessment (9-36%; two studies), and bladder diary (0-92%; nine studies), while there was high adherence to urine analysis (40-97%; nine studies). For the conservative management of UI, studies revealed a poor-moderate adherence to recommendations for pelvic floor muscle training (5-82%; nine studies), bladder training (2-53%; eight studies) and lifestyle interventions (1-71%; six studies). Regarding pharmacotherapy, PCPs predominantly prescribed antimuscarinics (2-46%; nine studies) and oestrogen (2-77%; seven studies). Lastly, PCPs referred those reporting UI to medical specialists (5-37%; 14 studies). Referrals were generally made <30 days after diagnosis with urologists being the most sought out professional to assess and treat UI.

CONCLUSION

This review revealed poor-moderate adherence to clinical practice guideline recommendations. While these findings reflect high variability in reporting, the key message is that most aspects of patient care for female UI provided by PCPs needs to improve.

Use of comprehensive geriatric assessment in general practice: results from the 'Senta Pua' project in Brazil

BACKGROUND

General practitioners (GPs) are responsible for most of elderly consultations in Brazil. Being aware of the needs of older adults is important for these professionals. A comprehensive geriatric assessment (CGA) is an important tool for assessing the elderly.

OBJECTIVE

The aim of this study was to evaluate (a) whether a CGA can identify previously unknown health problems, and (b) whether a CGA is accepted by elderly patients.

METHODS

We conducted a cross-sectional study by inviting all outpatients of the Sao Paulo Air Force Hospital aged 60 years and older to participate. Consenting patients were examined using a CGA. Health problems revealed by the assessment were compared to those previously known from the patients' charts. Patients' acceptability of the CGA was evaluated by a short questionnaire.

RESULTS

170 patients were included in the final analysis. Mean age was 75.7 years (SD: 8.0 years), 65.8% was female. On average, patients had 3.2 (SD: 1.9) geriatric problems gleaned from their charts and 9.0 (SD: 3.2) revealed by CGA. The most common health problems disclosed by the CGA were pneumococcal vaccination more than 3 years earlier, followed by sleep disorder, sedentarism, urinary incontinence, fall risk and cognitive impairment. The mean duration of CGA was 52 min and patient acceptability was high.

CONCLUSION

The present study using the CGA in a population of patients aged 60 and above disclosed, on average, 6 medical problems previously unknown to the GP. The acceptability by patients was good.

Targeting community-dwelling urinary incontinence sufferers: a multi-disciplinary community based model for conservative continence services

This paper presents an argument that there is a need to provide services that target community-dwelling incontinence sufferers, and presents a demonstration case study of a multi-disciplinary, community-based conservative model of service delivery: The Waterworx Model. Rationale for approaches taken, implementation of the model, evaluation and lessons learned are discussed. In this paper community-dwelling sufferers of urinary incontinence are identified as an underserved group, and useful information is provided for those wishing to establish services for them. The Waterworx Model of continence service delivery incorporates three interrelated approaches. Firstly, client access is achieved by using community-based services via clinic and home visits, creating referral pathways and active promotion of services. Secondly, multi-disciplinary client care is provided by targeting a specific client group, multi-disciplinary assessment, promoting client self-management and developing client knowledge and health literacy. Finally, interdisciplinary collaboration and linkages is facilitated by developing multidisciplinary assessment tools, using interdisciplinary referrals, staff development, multi-disciplinary management and providing professional education. Implementation of the model achieved greater client access, improvement in urinary incontinence and client satisfaction. Our experiences suggest that those suffering urinary incontinence and living in the community are an underserved group and that continence services should be community focussed, multi-disciplinary, generalist in nature.

Urinary incontinence, its influence on daily life, and use of continence aids in two cohorts of 85/86-year-old free-living men and women, born 10 years apart

The aim of this study was to assess the prevalence of urinary incontinence and other urinary tract symptoms, the use of incontinence aids and how urinary incontinence influences daily life in two 85/86-year-old cohorts born 10 years apart. There were no statistically significant differences between the two cohorts except for the use of incontinence aids, where 23% of women born in 1901/1902 and 42% of women born in 1911/1912 used aids (P=0.002). In this study, urinary incontinence was common among 85/86-year-old men and women but there were no significant differences except for the more frequent use of incontinence aids among women born in 1911/1912 than among women born in 1901/1902. The reason for this difference regarding use of incontinence aids among women could be that taboos are gradually lifting in many cultures, for example in Sweden, but so far mostly for women.

[Communication, diagnosis and treatment of urinary incontinence in the elderly in a basic health area]

OBJECTIVE

To investigate the frequency in which aged people who suffers on urinary incontinence (UI) talk about this problem with primary care professionals, variables related to no healthcare-seeking as well as diagnostic and therapeutic habits of these professionals.

DESIGN

Cross-sectional study.Location. Basic Health Zone of Cabra (Córdoba, Spain).

PATIENTS

A random age-stratified sample of 869 patients selected from a total of 5139 persons >= 65 years of age.Interventions. Home interview.

MEASUREMENTS

Proper questionnaire with questions about reporting of incontinence to health professionals and the procedures used for routine screening as well as diagnostic and therapeutic assessment of incontinence. A logistic regression model was elaborated to identify explanatory factors for reporting incontinence to healthcare professionals.

RESULTS

Of 330 incontinents, only 32% reported their problem to healthcare professionals. The remaining 68% did not report their incontinence because most thought it was a minor problem and/or part of the ageing process. The explanatory factors for seeking medical help were the frequency, duration and impact of incontinence, and dependence in self-care. Physicians performed routine screening for incontinence in 10% of 827 inquired aged. In 1 out of 5 incontinents, the physician did not take any diagnostic or therapeutic measures.

CONCLUSIONS

Seeking of UI medical help was very limited and depends on variables related to perception in symptom's changes. Diagnosis and treatment done by professionals was suboptimal. Severity of UI conditions diagnosis and treatment.

To treat or not to treat: issues in decisions not to treat older persons with cognitive impairment, depression, and incontinence

OBJECTIVES

To examine decisions not to treat problems identified during outpatient geriatric assessment, particularly problems of cognitive impairment, depression, or urinary incontinence.

DESIGN

A descriptive study using patients' medical charts and survey data and interviews with clinical staff.

SETTING

Four hospital-based, ambulatory, geriatric assessment clinics in Allegheny Country, PA.

PARTICIPANTS

The sample comprised 128 older adults, recruited to a randomized, controlled clinical trial, who had problems associated with cognitive impairment, depression, or urinary incontinence.

RESULTS

Although treatment was recommended for most of the problems relating to cognitive impairment, depression, and/or incontinence experienced by this group, slightly more than one-third of cognitive impairment and depression problems and nearly one-half of incontinence did not receive treatment recommendations. Treatment rates varied considerably by condition and combination of comorbidity. Decisions not to treat are classified into six categories: patient or family refused treatment, the assessment was not completed, an intervention was already in place, concurrent problems or comorbities might have interfered with treatment, there was no documented diagnosis or there was a documented consideration and rule out of the problem, or no documented reason.

CONCLUSION

Outpatient geriatric assessment units are designed to deal with the multiple problems experienced by their geriatric patients, and they identify successfully most problems presented by their frail constituents. However, identification of the patient's problems is only the first step in the assessment process and does not necessarily lead to either a documented diagnosis or to a treatment recommendation. Multiple social, cultural, environmental, and medical factors complicate the assessment process and, hence, the decision clinicians face when they decide whether to make recommendations to treat. These clinicians must weigh all medical and non-medical factors, including the patient's receptivity to treatment, when prioritizing the problems they deem to be treatable and making recommendations to treat.

Managing geriatric syndromes: what geriatric assessment teams recommend, what primary care physicians implement, what patients adhere to

OBJECTIVES

To evaluate the responses of primary care physicians and patients to recommendations from a community-based comprehensive geriatric assessment (CGA) program for management of four target conditions: falls, depression, urinary incontinence, and functional impairment.

DESIGN

Case series.

SETTING

Senior centers, meal sites, senior housing, and other community sites as screening locations; and a community-bases academic practice as the location for CGA.

PARTICIPANTS

A total of 150 older patients living in the community who have one or more of the four target conditions and who received CGA.

MEASUREMENTS

Physician implementation and patient adherence rates were ascertained during a face-to-face structured interview with the patient 3 months after CGA.

RESULTS

Two hundred twelve of 528 (40%) CGA recommendations were clearly or possible related to the target or target-related conditions. Of these 212 recommendations, 59% required a physician's order for implementation. The remaining 41% were patient self-care recommendations. Overall physician implementation across conditions was 70%; implementation rates were highest for falls and lowest for functional impairment. Overall patient adherence rate was 85% for physician-implemented recommendations and 46% for self-care recommendations. Patient adherence to recommendations for counseling or support groups and exercise programs was particularly low.

CONCLUSIONS

When examining the process of care of community-based CGA, patient as well as physician adherence must be considered. Although patient adherence to physician-initiated recommendations was high for all conditions, it varied substantially across target conditions and types of recommendations for self-care recommendations.

Evaluation of outpatient geriatric assessment: a randomized multi-site trial

OBJECTIVE

To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care.

DESIGN

Randomized, controlled clinical trial, with 12-month follow-up.

SETTING

Four hospital-based ambulatory geriatric assessment clinics and community physicians' offices.

PARTICIPANTS

442 recruited older adults with a health problem or recent change in health status.

INTERVENTION

Outpatient consultative geriatric assessment or usual physician assessment.

MAIN OUTCOME MEASURES

Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well-being.

RESULTS

Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group.

CONCLUSIONS

Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow-up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects.