Serial incontinence assessment in elderly inpatient men

Evaluation of an electronic monitoring device for urinary incontinence in elderly patients in an acute care setting

AIM

The primary aim of this study was to determine whether the use of habit training with an electronic monitoring device is better than standard habit training in the assessment and management of urinary incontinence in elderly patients in acute care hospitals. The second aim was to describe nurses' perceptions of continence management in acute care settings.

DESIGN

A randomized controlled trial was conducted for an 18-month period.

SAMPLE AND SETTING

The sample consisted of 41 elderly incontinent patients who resided on the acute care rehabilitation wards of 2 western Australian hospitals.

INSTRUMENTS

A continence assessment form was used to document self-reported or carer-reported frequency and severity of incontinence. A continence monitoring chart was used to record voiding patterns and continence outcomes. A semi-structured interview guide was developed to elicit nurses' perceptions of continence management.

RESULTS

Findings revealed no significant improvements in the self-reported or carer-reported frequency of incontinence from baseline to follow-up of in-patients and at 1 month after discharge, although there was a trend toward improvement in both the experimental and the control groups at the posttest time points. A significant reduction in self-reported or carer-reported severity of incontinence was demonstrated in the experimental group at 1 month follow-up (P = 5.025).Nurses' perceptions of continence management of elderly patients in acute care settings ranged from positive to extremely negative. Even those with positive perceptions were challenged by problems with device malfunction, perceptions of lack of time, lack of support from other staff, and lack of knowledge about how best to meet the continence management needs of this complex group of patients.

CONCLUSION

The potential value of an electronic monitoring device for reducing incontinence could not be adequately assessed because of the small sample size and problems with the device and with implementing the study protocol. Although it was possible to determine a pattern in voiding times using the electronic device, compliance with the toileting regimen was difficult to achieve.Researchers and clinicians planning future studies with this device should be aware of the practical limitations associated with habit-training regimens for elderly patients in the acute care setting.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

Special considerations in elderly individuals with urinary incontinence

OBJECTIVES

To describe special considerations related to the etiology, evaluation, and treatment of urinary incontinence (UI) in the elderly.

METHODS

The characteristics of UI in older patients are contrasted with those in younger patients. Recommended evaluations for elderly individuals are reviewed, and treatment issues are addressed.

RESULTS

The etiology of UI is more complex in older than in younger patients, and a different clinical approach is required. Bladder overactivity is a common underlying component of UI in the elderly patient regardless of the complexity of the etiology. The most common voiding symptom in elderly patients is urgency with urge UI. The evaluation of the older patient with UI should include a symptom assessment, physical examination, review of the medical history (particularly with regard to previous surgeries), and assessments of social environment and functional status (which can have an impact on the type of treatment selected and the success of therapy). Urodynamic evaluations are particularly important because of the complexity of UI in this population. Treatment options include pharmacologic therapies, behavioral interventions, electrical stimulation, and combination therapies. The combination of surgical and nonsurgical therapies may be particularly important in the future.

CONCLUSIONS

Control of bladder overactivity is the most significant long-term challenge in the management of UI in the elderly. Successful treatment can produce a marked improvement in the quality of life for these individuals.

Urinary incontinence in nursing homes: incidence, remission and associated factors

OBJECTIVE

To determine the incidence and remission rates of daytime urinary incontinence (UI) in a cohort of newly admitted nursing home (NH) residents.

DESIGN

Prospective cohort study.

SETTING

Eight proprietary NHs in Maryland.

SUBJECTS

Four hundred thirty new admissions age 65 or older who were participants in a larger prospective study of mental morbidity and adjustment to the NH.

MEASURES

Nurses aides' reports of continence status, psychiatric examinations, and nursing staff assessments of mobility at 2 weeks, 2 months, and 1 year after NH admission.

RESULTS

The prevalence of daytime UI at admission was 39% in both females and males. Among the 293 members (68%) of the admission cohort remaining in the NHs 2 months after admission, the incidence of daytime UI was 27% (21% in females, 51% in males); daytime UI resolved in 23% (24% in females, 20% in males). Among the 178 members (41%) of the admission cohort remaining in the NHs 1 year after admission, the incidence of daytime UI between 2 months and 1 year after admission was 19% (16% in females, 46% in males); daytime UI resolved in 22% (23% in females, 14% in males). The continence status of about two-thirds of residents remaining in the NH at 1 year after admission was stable over time: 22% had daytime UI, and 42% were continent at all three data collection points. The development of daytime UI was associated with male sex, the diagnosis of dementia, fecal incontinence, and the inability to ambulate or transfer independently. Resolution of daytime UI was associated with the absence of these characteristics.

CONCLUSIONS

Despite limitations attributable to the method of defining UI and potential biases related to the attrition of the admission cohort over time, this is the first large prospective study to examine the incidence and remission patterns of daytime UI among NH residents. The strong association between UI and dementia was validated for the first time by direct psychiatric examinations. Sex and mobility are also closely associated with the development and remission of UI in this setting. This study provides some valuable data that can be used to assess the impacts of the recently developed Resident Assessment Protocol for UI and Agency for Health Care Policy and Research Clinical Practice Guidelines.

Nighttime sleep and bed mobility among incontinent nursing home residents

OBJECTIVE

To describe sleep and body movement patterns in incontinent nursing home residents for the purpose of determining if the residents require nighttime changing and body repositioning on a 2-hour schedule.

DESIGN

Cross-sectional survey.

SETTING

Four nursing homes.

PARTICIPANTS

118 nursing home residents.

MEASUREMENTS

Over two nights, bedside monitoring equipment recorded wrist activity (as a proxy measure for sleep) and body movements of both the shoulder and hip areas in consecutive 2-minute intervals. Specific outcome measures were: (1) Average duration of a sleep episode, peak duration of a sleep episode, and percent of time in bed asleep. (2) The number of 2-minute intervals in which a large movement (45 degree turn) at the shoulder and hip was noted per hour of recording for each resident. (3) The number of resident-initiated, rather than staff-initiated, large movements at the shoulder and hip that occurred within the same 2-minute intervals.

RESULTS

There was large variability in all sleep measures; however, on average, residents slept 66% of the time they were in bed. The distribution of these measures suggests that sleep was punctuated with frequent nighttime awakenings. Thirty-three percent of the incontinent residents demonstrated very low levels of resident-initiated movement at the shoulder and hip. Sixty-six percent demonstrated at least one large movement at the shoulder and hip per hour during periods of sleep as well as during periods of wake.

CONCLUSION

The majority of incontinent nursing home residents self-initiate sufficiently frequent movements at both the shoulder and hip so as not to be in need of frequent repositioning by nursing staff. Since the sleep of many of these residents is also characterized by frequent awakenings, incontinent nursing home residents may benefit from a schedule of nursing care at night that considers sleep of equal importance to incontinence care and body repositioning.

Volume-interval relationship of incontinence episodes in elderly inpatient men

Urinary incontinence is an immense source of personal distress for older people. The characteristics of urinary incontinence in older people that contribute to understanding the pathophysiology of incontinence have not been studied extensively. In this study, 66 elderly inpatients were monitored for incontinence characteristics of incontinence volume and time interval between episodes. There was no correlation between incontinence volume and time between episodes of incontinence. This supports a previous observation that the occurrence of urinary incontinence in elderly inpatient men is not determined by the accumulated volume of urine in the bladder.

The dark side of incontinence: nighttime incontinence in nursing home residents

OBJECTIVE

To describe the characteristics of nighttime urinary incontinence in a sample of nursing home (NH) residents.

DESIGN

Prospective descriptive study of a convenience sample of incontinent NH residents.

SETTING

Four NHs.

PARTICIPANTS

136 incontinent NH residents.

MEASUREMENTS

Frequency and volume of incontinent and continent voids for three 10-hour daytime and three 10-hour nighttime data collection periods.

RESULTS

The frequency of nighttime incontinence was the same as during the day, but the volume of nighttime incontinent voids and total nighttime volume were higher than during the day. There was substantial between- and within-subject variability in volumes, but the distribution of ratios of night/total volumes approximated a normal curve. Diuretic use was associated with relatively low nighttime volumes.

CONCLUSION

About one-quarter of the NH residents we studied produced substantially more urine at night than during the day. Several medical, behavioral, and environmental approaches should be considered for reducing the frequency and volume of nighttime incontinence in this population.

Urinary incontinence: an augmented prompted void approach

Continence improves from 44.7% dryness at baseline to 54.7% at the end of treatment, an improvement of 22%, or about one incontinent episode per day. Urinary incontinence is improved in cognitively impaired residents by augmenting the prompted voiding procedure with a bellpad. Bladder behavior changes with behavioral treatment strategies, because the volume voided into an appropriate receptacle increased an average of 26 mL per 2 hours. Reimbursement policies should not exclude treatment of the severely cognitively impaired nor the immobile in nursing homes.

The effects of patterned urge-response toileting (PURT) on urinary incontinence among nursing home residents

OBJECTIVE

To test an individualized form of habit training for urinary incontinence (UI) among long-stay cognitively and/or physically impaired elderly nursing home residents over time.

DESIGN

Randomization of subjects occurred by nursing home unit. Baseline wet checks were done hourly for one 24-hour period at 3-week intervals over 12 weeks followed by 72 hours of continuous electronic monitoring to establish precise voiding patterns for each subject. The 12-week intervention period was administered by indigenous staff after they attended a 4-hour UI educational program. Subjects were followed an additional 12 weeks to determine the extent of maintenance of the intervention among staff and subjects.

SETTING

Four non-profit nursing homes; west, mid-west, east coast.

PATIENTS

Consent was obtained from 154 (71%) who met primary inclusion criteria. Forty-one failed the secondary inclusion criteria leaving 113 who entered the 37-week study. Eighty-eight completed the study (experimental = 51, control = 37); all were physically and/or mentally impaired, averaged age 85, and had either urge or urge/stress UI.

RESULTS

UI was significantly decreased during the 3-month period (P less than 0.001). Eighty-six percent showed improvement over baseline while one-third improved 25% or more over their baseline UI rate. The control group's UI increased during the same period of time. The volume of UI among the experimental group also decreased (P less than 0.005) while the control group's UI volume increased.

CONCLUSIONS

The training program was effective in reducing UI though compliance among nursing staff averaged only 70% of the prescribed toileting times. The success of this approach is similar to other recently described behavioral programs but achieved the reduction using only regular nursing staff. This individualized approach supports the recent regulatory thrust to individualize care to promote and maintain functional abilities and autonomy.