2Organizational GoalTo organize continence services in an integrated fashion that focuses on the identification of patients, assessing their condition and implementing the most appropriate treatment plan. This model of good practice will allow staff to achieve more responsive and effective continence services and assist patients.
3SPPICES QuestionsDo you have problem passing water/getting to the bathroom on time?Did you wear incontinence products at home?If there is a catheter, is it still needed?Was your last bowel movement 3 days ago?
4Did you know that... 50% - 70% of persons with UI don’t seek help. UI is a very common problem with treatments that work.Most cases of UI can be markedly improved.Reasons for not seeking help unclear but linked to:too embarrassedhope it will improve without interventionnormal part of aging and / or nothing can be doneafraid of needing an operationdon’t perceive it as s serious problem compared to those who seek help
5Prevalence 15% - 30% of seniors in the community 15.3% in acute care facilities50% in nursing homes15% = males; 30% = femalesrates vary between 8-51% because of: closet issue - too embarrassing to reportunsure of true extent % of people don’t seek helpproblems with research (some use subjective report, white women, depends how question asked, varying levels of incontinence
6Impact of UI Physical Psychosocial Financial Physical falls, fractures urosepsisskin breakdownPsychosoocialsocial isolationembarrassment, feelings of shamelonelinessstress on family/ caregiverFinancialaffects discharge from hospital or acceptance to RH, rehabone study found 44% of families who institutionalized their loved ones cited difficulty managing continence as reason for admissionimpact on family - children - sonsincrease time for care in hospital/NHcost of incontinent pads, briefs, laundering, catheters
7DefinitionA common, disruptive, and potentially disabling condition in the aging population.An involuntary loss of urine in sufficient amounts or frequency to constitute a social and/or health problem.(Kane, Ouslander, & Abrass, 1994)Key issocial/ health problemself described
8Requirements for Continence Effective lower urinary tract functioning storage & emptyingAdequate mobility and dexterity to use the toilet, toilet substitute, and to manage clothingAdequate cognitive function to recognize toileting needs and to find a toilet/substituteMotivation to be continentAbsence of environmental and iatrogenic barriers such as inaccessible toilets/substitutes, unavailable family/caregivers and drug side effects
9Established/Persistent UI: The Bladder Normal Aging ChangesAnatomyPhysiologyAging itself does not cause UI!!Aging does contribute to:Decrease in bladder capacityIncrease in residual urineInvoluntary bladder contractionsA 30%-40% loss of functional cells in the kidneys (nephrons)A decrease in the kidney’s ability to filter blood and concentrate urineWearing out of the sensory nerve tract from brain to bladderand these can put people at greater risk of UIDecrease in bladder capacity – leading to the bladder not emptying fully leading to increase in frequency and residual urine leading to UTIs from the urine left in the bladderBladder spasms create the “sensation to void” before the bladder is full leading to urge incontinence while patients are walking to the bathroomMen ~ prostatic enlargement causes a decrease in urine flow & detrusor motor instabilityWomen ~ decline in bladder outlet and urethral resistance pressure
11Causes of Acute/Reversible UI D DeliriumI InfectionA Atrophic Vaginitis/ UrethritisP PharmaceuticalsP Psychological causesE Excess fluidR Restricted mobilityS Stool impaction(Resnick, 1992)List of causes:Delirium/confusional stateInfection - 30% of hospitalized seniors have asymptomatic bacteruria. Ouslander (1992) recommended that incontinent elderly pts with significant bacteruria be considered symptomatic vs. asymptomaticAtrophic vaginitis - results from low estrogen levels in postmenopausal womenpharmacueticals - caffeine, diuretics, sedatives/hypnotics, narcotics, anticholinergics, calcium channel blockers all can contributepsychological causes - depression, anger, hostility toward caregiver, regression in psych ptsexcess fluids - from high fluid intake (esp caffeine) or from volume overload with venous insufficiency or CHF endocrine problems like hyperglycemia and hypercalcemia both cause polyuria and can also trigger incontinencerestricted mobility - surgery, fracture, restarints, arthritis, neurostool impaction - causes outlet obstruction has been cited as a primary cause of incontinence occurring in 5-10% of frail NH pts
12Established UI: Overflow Urine loss (dribbling) associated with an overdistended bladder due to an obstruction in the urethra.Signs and Symptoms:Leakage of small amounts of urinePalpable or percussable bladder, suprapubic tendernessHesitancy on voiding, interrupted urine flow or post void dribblingUrine loss without urgeSensation of incomplete voiding or bladder fullnessFrequencyThis implies that the bladder cannot empty completely, retains urine, becomes overdistended, and then overflows.It is characterized by the constant leakage of small amounts of urine from a filled bladder.Causes:outlet obstruction: prostatic hypertrophy, fecal impaction, urethral stricture, pelvic organ prolapse (cystocele)chronic myogenic decompensation: peripheral neuropathy (DM, spinal cord injury, MS)acontractile, hypotonic, or underactive detrusor d/t anything that overdistends the bladderpt with 2000 cc emptied from bladder
13Established UI: UrgeInvoluntary loss of urine (usually larger amounts) associated with a sudden, strong desire to void.Signs and Symptoms:Sudden “urgency” to voidNocturia and / or EnuresisModerate to large amounts of urine lossLoss of urine at the sound of water running or when waiting to access a public toiletNocturia = excessive urination at night; it may occur in older people who have excess fluids that are mobilized when theylie down at nightEnuresis = incontinence of urine, especially in bed at night- unlike stress incontinence where small amount of urine lost, urge incontinence usually involves larger amountsCauses:lower urinary tract = UTI, cystitis, bladder tumour, bladder stones, urethritis, atrophic vaginitiscentral nervous system = CVA, dementia, Parkinsons, NPH, MSabove result in uninhibited detrusor contractionsthese can also be caused by deconditioned voiding reflexes (ie frequent voiding to reduce risk of incontinence) - this reduces bladder capacity and with time the bladder wall thickens, aggravating the condition of decreased tone and increased instabilityincont d/t inhibited detrusor contractions in the absence of a neurological disorder is also called detrusor motor instabilityUsually caused by an “unstable bladder” or “detrusor instability” isolated or associated with CNS disorders.
14Established UI: Functional Urinary leakage associated with the inability to toilet because of impairments in cognition and/or physical functioning, psychological unwillingness or environmental barriers.Signs and Symptoms:Report of being unable to get to the bathroom on timeTotal emptying / large amounts of urine leakageNo incontinence when access to a bathroom and assistance with toileting availableCauses:Evidence of impaired mobility, manual dexterity, communication or cognitive skillsDepression, anger, hostilityPhysical and/or chemical restraints
15Established UI: Stress An involuntary loss of urine (usually small amounts) with increases in intraabdominal pressure (ie. Cough, laugh, sneeze, exercise).Signs and Symptoms:Small amounts of urine leakage/loss associated with activity, lifting, coughing, sneezing, and/or laughingUrine leakage during the day while person is activeMost common type of UI in women, less frequent in menCauses:incompetent urethraweak pelvic floor musculatureWomen – multiple childbirths, estrogen deficiency, trauma to external urinary sphincterMen – pelvic trauma or sphincter damage during prostatectomyObesitySmoking with chronic coughingPathophysiologylosses of small amounts of urine in the absence of a detrusor contraction usually during sudden increases in intra-abdominal pressure (from coughing, sneezing, etc).The underlying cause is the inability of the urethra to sustain pressure that exceeds that of the bladder, particularly under exertional events
16Interventions Environmental Alterations Lifestyle Management Scheduling RegimesPelvic Muscle RehabilitationContinence ProductsCatheterizationOcclusive & Pelvic Organ Support DevicesMedicationSurgeryIntervention based on type of incontinence, severity and impact on life, pts cog and functional status, pt/caregivers preferences and expectations, cost-benefit factorsassessment - voiding record, PVREnvironmental Alterations - lighting, commode/urinal by bed, skirts vs pants for women; zippers vs. buttons; RTS; loose fitting clothesLifestyle Management - reducing caffeine intake, weight reduction in obese people, reduce smoking to reduce chronic cough, prevent constipation through diet and exerciseScheduling Regimes- timed voiding, habit training, prompted voiding, bladder trainingPelvic Muscle Rehabilitation - pelvic muscle exercises, vaginal weight training, biofeedback, electrical stimulationContinence ProductsCatheterizationOcclusive & Pelvic Organ Support Devices - penile compression devices, pessaries (for pelvic organ prolapse)Medication - estrogen, oxybutininSurgeryPTproper skin care
17URGE STRESS FUNCTIONAL New onset urinary incontinenceRisk factors identified: Delirium/confusionInfection, urinary symptomsAtrophic vaginitis/urethritisPharmaceuticalsPsychologic disordersEndocrine disordersRestricted mobilityStool impactionFrequencyNoctuiraEnuresisModerate to large amount of urine lossFrequent urinationPost void dribblingRetentionHesitancySensation of fullness/pressure in abdomenUrine loss without urgeUnable to get to toilet on timeSmall amount urine lossAssociated with activity,CoughingSneezingBladder trainingKegel exercisesLiners/briefs if neededEnvironmental modificationsConsider medical referral as indicatedProvide urinal/commodeSubjective/objective report of improvementDecreased use of liners/briefsKegel exerciseBladder diary to establish routineMonitor weeklySubjective report of in incontinent episodesAllow patient sufficient time to voidEncourage double voidPVR using bladder scannerContact MD if appropriate for I/O or catheterization orderProvide urinal or commodeMedication reviewPVRMonitor daily then weeklyScheduled toiletingAvoid restraintsEnsure toilet accessibleProvide commode etc at bedsideModify fluid intake patternModify environment eg remove obstaclesEnsure adequate lightingOT/PT assessmentMonitor weeklySubjective/objective report of in incontinence episodesClinical AssessmentSymptomsInterventionsEvaluationType of IncontinenceURGESTRESSOVERFLOWFUNCTIONAL
18Case StudyMr. Yeung is a 90 year old man with a history of dementia, CHF, and osteoarthritis. He is on 40mg lasix BID, and Tylenol # 3 prn for his pain. During his hospitalization for exacerbation of his CHF, he has a new onset of urinary incontinence.What type of UI is Mr. Yeung experiencing?What would be your plan of action for him?What meds is he on?Is he constipated?Is his intake adequate?What’s his level of cog. Fx r/t dementia?Does he have a UTI?Does he have any mobility problems preventing him from getting to the toilet?Is he retaining urine?CLUES…Lasix, PVR = 30cc. Urine neg., bowel Normal, patient is not aware of when he needs to void or where the BR is, he is having difficulty getting to the BRMR. JONES HAS FUNCTIONAL INCONTINENCE!!InterventionsOT to Ax cog. Fx; ability to find BR, remember where it is, ability to pull pants up/down and safety issues/barriers in environmentPT to Ax mobility and ability to get on/off toilet safelyNursing to start voiding record to establish his normal voiding patternNursing to begin scheduled toileting routine Q2-4 H on days and Q4-6 on nights, or one that matches patient’s normal routine at home or as assessed from recordOT/PT/Nursing attempt to get patient to use urinal if possible as assessed via cog.fx Ax by OT