1. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Continence: A Matter of Dignity Care of Chronic and Complex UI By Marie Mangino, MSN, CRNP, BC President, Vincent Healthcare, Inc. Consultant, Penn Nursing Consultation Service

2. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Acknowledgements Appearing in Video: Name Appearing as Bob Swensen……….Mr. Banks Ruth Alpert…………Mrs. Banks Susaye Lawson…… Susaye Nate Lazowick…….Mr. Williams Kevin Brown……… Carl, DCSW Dinnie Childs………Piano Player Clarese Herbert……Mr. William’s friend Man at Piano………Arjun Bhojwani Nancy Web…………Mrs. Powell Eric Stewart……….Mike, grandson Ruth Livikoff………Ruth, DCSW Name Appearing as Dick Brown………………Mr. Clark Deanna Penn…………….Supervisor Sangeeta Bhojwani…….Trainee Roby Jacobs……………..Daughter Charlene Duff……………Shopper, Gift Shop Sheila Mitchell-Ayers…Shopper, Gift Shop Marie Mangino………….Trainer, as herself Tanisha Jones……………Testimonial Julie Cohlmer…………….Testimonial

3. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Special thanks to: Henrietta Roberts and Sandy Bailey, of Stapeley in Germantown for coordination of video shoot All the residents and staff of Stapeley in Germantown, for their participation and for permitting video production. Raybourn Rusk Productions

4. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Review of “Causes, Signs and Prevention” The first module covered the following objectives as learner outcomes:  List the common causes of Urinary incontinence (UI)  Describe the potentially serious effects of not treating UI  Recognize signs of a UTI  Discuss effective ways to prevent or reduce episodes of UI and enhance dignity

5. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Learning Objectives At the end of “Care of Chronic and Complex Urinary Incontinence” you will be able to:  List the major types of chronic UI and the common signs and symptoms of each  Explain the importance of preventing constipation in older adults with UI  Discuss creative approaches to more complex cases of older adults with UI  Provide care to prevent or reduce episodes of UI and enhance dignity

6. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Types of Chronic UI  Stress  Urge /Overactive bladder  Overflow  Functional  Mixed

7. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Stress UI  Small amount of urine leakage  Loss of urine with increased pressure in the abdomen from:  Coughing  Sneezing  Laughing  Lifting  Standing

8. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Stress UI : How You Can Help?  Set toileting schedule based on a log and stick to it  Expect small leaks; use a liner

9. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Stress UI : How You Can Help?  Change more frequently  Use skin barrier Mrs. Levy

10. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Urge UI (Overactive Bladder)  Involuntary loss of urine and a strong urge to urinate that occurs suddenly  May be incontinent on the way to the bathroom  May be incontinent of a large amount of urine Mrs. Powell w/walker

11. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Urge UI (Overactive Bladder): How You Can Help  Encourage person to avoid bladder irritants  Stick to personalized schedule  Watch for signs of need to toilet  Keep urinal or commode handy  Expect heavier wetting with longer period of dryness

12. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Mrs. Powell’s Success

13. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Case of Mrs. Powell  Remind the person to avoid bladder irritants (including sodas, caffeine, alcohol and artificial sweeteners)  Help by establishing a toileting schedule and sticking to it  Watch for signs of need to toilet

14. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Overflow UI  Continuous or periodic leakage of small amounts of urine  Tension in bladder forces muscles to leak small amounts, either continuously or off and on  Caused by either  Blockage at the exit of the bladder (large prostrate)  Bladder, nerve or muscle damage Mr. Stanley

15. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Overflow UI: How You Can Help  Allow time to stand and wait  Report complaints of discomfort  Report inability to urinate for more than 8 hours or urination every hour  Watch for signs of mental status change  Maintain schedule for toileting

16. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Functional UI Due to chronic functional impairment:  Confusion  Physical disabilities  Combination Mr. Clark

17. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Functional UI: How You Can Help  Set toileting schedule based on the log and stick to it  Encourage clothing that is easy to remove  Assist as needed  Praise successes and effort

18. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Challenging Situations  Dementia  Inappropriate toileting  Denial  Unsafe attempts to toilet  Chronic constipation

19. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center The Challenges of Dementia and UI  Inappropriate toileting  Denial of incontinence Mr. Clark

20. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Dementia and UI: How You Can Help  Never judge or disagree, accept the person’s explanation for wet clothing  Focus on  Changing and cleaning  Dignity and respect  Prompt (remind and encourage) to use the toilet, assist to get there, then prompt again

21. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Right Time, Right Place

22. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Case of Mr. Clark Focus on:  Dignity and respect  Changing and cleaning if needed  Prompt (remind and encourage) to use the toilet, assist to get there, then prompt again

23. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center UI and Unsafe Attempts to Toilet Due to:  Difficulty Walking  Poor vision  Poor safety judgment

24. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Unsafe Attempts to Toilet: How You Can Help  Use individualized toileting schedule; be there ahead of time  Do not rely on call bell  Do not wait until the person tries to get up

25. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Unsafe Attempts to Toilet: How You Can Help  Use safe footwear  Use proper eyeglasses when walking; assist person wearing bifocals  Provide a bedside commode or urinal to reduce the need to walk alone

26. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Chronic Constipation and UI  Presence of stool in the pelvis  Takes up room in the pelvis so bladder cannot fill up  Causes need to urinate more often  Increases incontinent episodes

27. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Chronic Constipation and UI: How You Can Help  Report it  Encourage  Fluid intake  Activity  Foods rich in fiber  Avoid constipating food

28. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Objectives Review Can you now 1.List the major types of chronic UI and the common signs and symptoms of each? 2.Explain the importance of preventing constipation in older adults with UI? 3.Discuss creative approaches to more complex cases of UI in older adults?

29. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Closing

30. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Special Thanks To: Christine W. Bradway, PhD, CRNP Assistant Professor of Gerontologic Nursing University of Pennsylvania School of Nursing Mary Ann Forciea, MD Clinical Associate Professor of Medicine Director, Primary Care Services University of Pennsylvania Health Systems Nicole Mangino Illustrator

31. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center References and Resources Burgio, K. L., Robinson, J. C. & Engel, B. T. (1986). The role of biofeedback in Kegal exercise training for stress urinary incontinence. American Journal of Obstetrics & Gynecology, 154: 58-64. Choe, J. M. (1999). Freedom regained: Female urinary incontinence can be overcome. Columbus, Ohio: Anadem Publishing; 117-171. Clinical practice guideline number 2: Urinary incontinence in adults. Rockcville Md: US Department of Health and Human Services Agency for Health Care Policy and Research; 1996. AHCPR publication 96-0682. Gibbons, L. & Choe, J. M. (2005). Helping women quell urinary incontinence. The Clinical Advisor, 7 (5), 21-28.

32. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center References and Resources Langa, et al, (2002). Informal caregiving time and costs for UI in older individuals in the US. Journal of the American Geriatrics Society, 50,(4): 733-737. Lee SY, Phanumus D. & Fields S.D. (2000). Urinary incontinence: a primary care guide to managing acute and chronic symptoms in older adults. Geriatrics, 55(11): 65-72. Morkved, S. Bo, K. & Fjortoft, T. (2002). Effect of adding biofeedback to pelvic floor muscle training to treat urodynamic stress incontinence. Obstetrics & Gynecology, 100; 730-739. Multiple authors (2004). Special issue: Urologic care of the older adult. Urologic Nursing, 24, 247-333. Teunissen, T.A.M., de Jonge, A., van Weel, C., & Lagro- Janssen, A.L.M. (2004). Treating UI in the elderly— conservative measures that work: A systematic review. Journal of Family Practice, 53 (1), 25..

33. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center References and Resources Web sites: Collaborative to Support Urinary Incontinence and Women’s Health www.stressUI.org National Association for Continence: www.nafc.org National Institute of Diabetes & Digestive & Kidney Diseases: www.niddk.nig.gov

34. TLCTLC TLCTLC LTCLTC LTCLTC © 2006 University of Pennsylvania Delaware Valley Geriatrics Education Center Leadership and Staff: Lois K. Evans, DNSc, RN, FAAN Series Associate Editor Viola MacInnes Independence Professor School of Nursing University of Pennsylvania Sangeeta Bhojwani Associate Director, Series Assistant Editor DVGEC University of Pennsylvania Laura Raybourn Sally Rusk, Consultants Raybourn Rusk Productions Kathleen Egan, PhD Series Editor DVGEC Program Administrator Director, DVGEC University of Pennsylvania Mary Ann Forciea, MD Series Associate Editor Clinical Associate Professor of Medicine Division of Geriatric Medicine, University of Pennsylvania