Managing Urinary Incontinence Facilitator Guide Catherine Van Son, Ph.D., R.N.

“ A journey of a thousand miles begins with one step.” (or one drop) Lao-tse Learning Objectives: to describe UI and the impact the condition can have on the individual and society to differentiate the differences between the various kinds of UI, assessments, and treatments to state methods to minimize the impact of chronic incontinence There is no one single intervention for managing urinary incontinence. Management involves several steps that can lead to the reduction or elimination of incontinence.

Urinary Incontinence Defined as an involuntary loss of urine in sufficient amount or frequency to cause social and/or health problem Is not a normal consequence of... - aging - menopause - pregnancies (although physiological changes such as those listed may contribute to the development of incontinence) These conditions may contribute to episodes of UI, but UI is not an automatic consequence of these conditions. Other contributing factors: weight gain pelvic surgery prostatectomy lowered estrogen levels in menopause post childbirth (related to trauma to the pudendal nerve which innervates the pelvic musculature)

UI is not reported because of... embarrassment lack of information a belief it is part of aging health care providers don’t ask a belief there is no effective treatment fear of the therapies used to manage the problem Ask participants to discuss other reasons why UI is not addressed by: health care providers family members individuals with UI

Psycho-social Impact loss of self esteem embarrassment decrease in ability to maintain independence social isolation depression anxiety poor quality of life risk of institutionalization should not underestimate the psychological impact of UI should suspect UI as a possible cause when we see some of these behaviors in a study of cognitively intact homebound elders, those with UI perceived it as a problem that further restricted their activities. Subjects had a mean age of 75.8 years, a mean of 8.4 medical problems, and most 80%, had functional limitations in ambulation. --54% reported that UI further restricted their activities --52% reported that this problem was extremely disturbing. --90% believed that it could be treated. (JAGS Vol. 44 No.8 August 1996.) Handout: Family member with UI

Self-care behaviors used: locates or stays near a bathroom when out voids more frequently wears protective garment restricts fluid intake does not take certain meds if going out restricts social / physical activity Only one in 12 women with UI seeks diagnosis and treatment.

What is normal? daytime: nighttime: frequency of no more than once every 2 hours nighttime: 1-2 voidings are considered normal Daytime: every 2 hours, should be able to sit through a movie Nighttime: greater than twice a night is called Nocturia. This is extremely disruptive, with consequences such a falling when getting up at night to go to the bathroom, and sleep deprivation causing fatigue, forgetfulness, disorientation, and depression.

Age Related Changes decreased bladder capacity (normal is 500-600 ml., older adult capacity may be 250 ml.) increased residual urine increased involuntary bladder contractions decreased outlet resistance (females) decreased ability to inhibit contractions increased outlet resistance (males) In General: Bladder capacity: From 500-600ml to about 250 ml in older age Kidneys: decrease in size about 20 to 40% between ages of 40-90 less efficient at concentrating urine, causing an increase in urine volume Muscular structures: lose tone and elasticity such as the detrusor muscle resulting in incomplete bladder emptying decrease in the ability to postpone urination decrease in urethral closing pressure increase in spontaneous detrusor muscle contractions

Forces that Affect the Pelvic Floor Anatomical Neurological Why would the female anatomy increase incidence of urinary incontinence? In which ways do the nerves affect the pelvic floor? Pelvic Floor Hormonal How does estrogen affect the pelvic floor? Neurological: nerves that support musculature and organ function Mechanical: pressures from pregnancy, constipation and or prostate enlargement Anatomical: position of bladder, length of urethra Hormonal: role of estrogen Psychological: beliefs about UI and treatments Mechanical What is the impact of pregnancy, constipation, and/ or prostate enlargement ? Psychological How would one’s psychological status impact incontinence?

Risk factors for UI immobility/chronic degenerative disease impaired cognition medications obesity diuretics fecal impaction, constipation low fluid intake environmental barriers diabetes stroke estrogen depletion smoking Most of these factors can be managed and the impact on UI decreased. Additional risk factors: Immobility: Pain ambulation to BR difficult ( i.e. rheumatoid arthritis) Vision changes Each of these factors can increase one’s risk for experiencing urinary incontinence. Often older adults experience more than one risk factor at any given time.

Medications can cause... frequency urgency retention fecal impaction polyuria nocturia immobility sedation delirium Handout: Medications and UI

Incontinence History Medical History? Frequency? Sensations? Medications? Amount? Obtaining a history can be time consuming but is the most valuable part of the assessment / treatment process. Medical History: Diabetes CVA Parkinson’s Dementia Frequency: hourly, daily, weekly Amount: dribbles, small wet spot, soaked clothes Sensations: urgency, dysuria, no warning Medications: See medication handout

Incontinence Screening “DRIP” NOTE: Any one of these conditions can cause acute onset urinary incontinence and must be evaluated promptly ! D - delirium, depression R - retention, restricted mobility and/or environment I - infection, inflammation, impaction P - pharmaceuticals, polyuria, pain Causes of acute and reversible forms of urinary incontinence D- depression: may not feel like going to the BR delirium, dementia: may not know what to do in the BR R- retention: based on enlarged prostrate, or medications restricted mobility: restraints, needs CG assistance I- infections: UTI’s, urethritis, vaginitis impaction: fecal P- pharmaceuticals (see medication Handout) polyuria: diabetes, nocturia

Kinds of Urinary Incontinence Stress Functional Environmental Urge Overflow Iatrogenic (caused by hospitalization, medications, etc.) Mixed In addition there is... Mixed Incontinence - a combination of stress and urge Iatrogenic Incontinence -caused primarily by medications

Stress Incontinence loss of urine that occurs during activities that increase intra-abdominal pressure: coughing sneezing laughing physical activity (lifting heavy objects) caused by pelvic muscular weakness as a result of pregnancy obesity surgery medications aging (lower estrogen levels) Stress UI is the most common form of UI and the most treatable. Other potential indicators: getting up from a chair or out of bed when walking or other exercise frequent trips to the BR to avoid accidents

Pelvic Floor Muscle Exercises Intervention for stress incontinence Also known as Kegel exercises Requires 2-5 sets of pelvic muscle contractions done several times each day Feedback needed so client knows they are doing them correctly, such as... vaginal palpation biofeedback vaginal cones (Look this up; what are they and how are they used?) Like all exercises; success depends on doing them regularly. Other recipes: 5 minutes 2 times a day If prostate surgery is scheduled, pelvic muscles should be checked for strength (by same clinics that treat UI)

Functional Incontinence physical or psychological impairment that results in incontinence when the urinary tract is healthy causes: Decreased mobility Pain Clothing Psychological factors Focus on the individual’s ability to toilet him/herself Lack of toilet or toilet substitute Restraints Improper footwear, (fear of falling) Dressing / undressing issues (privacy) Medications causing polyuria / sedation Mobility issues: CVA, amputation Depression, Delirium, Dementia Pain (arthritis) May not remember what to do in the BR Task may be too complicated Doesn’t know when s/he needs to urinate How might these issues cause incontinence when the urinary tract is healthy?

Functional Assessment ability to put on /take off clothing sequence of tasks involved with toileting mobility: ability to ambulate, use a w/c and/ or transfer to and from the toilet access to toilet /device (such as urinals, bedside commodes, etc.) Simplify clothing: using velcro or elastic instead of buttons or zippers Encourage the use of undergarments whenever possible, gives the message to try to stay dry and use the toilet when wet. (See padded underwear in catalogs) Change clothes when wet, ASAP, so client doesn’t get accustomed to wet clothes Use easy to wash clothing and shoes (tennis shoes are easy to wash and provide a none slip surface to prevent falls on wet floors) Resources: Adaptive clothing catalogs (ex.Buck & Buck) Adaptive equipment OT evaluation catalogs See Learning activity:

Environmental Incontinence psychological message that UI is expected chairs are plastic beds are protected pads are available and applied “just in case” architectural design long corridors poorly marked bathroom doors caregiver attitudes “Go ahead and go (urinate), I’ll clean you up later.” “S/he does that on purpose.” (Episodes of incontinence) delay in removing wet clothing Definition: UI due to external barriers such as equipment, signs, building design and caregivers Signs can be a problem: see example Distances too far Floor & toilet same color making it hard to find the toilet Lack of privacy Poor lighting Clutter : pets, tubing, newspapers Bed may be too high, chairs too high & deep: difficult to get out TV ads for incontinent products assume that UI is a natural consequence of aging

Environmental Assessment location/ accessibility of toilets signs for bathroom call lights/ bells adaptive equipment cleanliness, safety “try a bright awning over BR door so it can be seen from a distance” (Robinson,A. et al,1996) paint BR doors a different color use signs in large print that say “Bathroom” &/or a picture of a toilet (Robinson,A. et al,1996) grab bars (placed in the BR and on the bed) keep BR floor dry to prevent falls adaptive equipment urinals / commodes raised toilet seats

A true story… Once there was a gentleman with mild cognitive impairment who was able to toilet independently. However, since coming to this new adult day center he has been voiding in flower pots and trash cans, and wandering into apartments next to the adult day center to use the bathrooms of tenants who live there, which they are not happy about. What should be done? Think about the environment.

Bathroom Signs What was puzzling is that he passed by four bathrooms that were designated for the participants in the adult day center. Upon further investigation, it was discovered that the day center bathroom doors were always closed due to fire regulations and the signs by the bathrooms were like the one here on the right. Could a person with mild dementia understand that this sign was for the bathroom? Typical signs found now outside public restrooms, however not well recognized by cognitively impaired. Make signs with actual pictures of toilet and use words like toilet & bathroom

Solution Since he could not tell us we had to make an educated guess. We enlarged a picture of a toilet, similar to this one and taped it to each of the day center bathroom doors. What do you think happened? (You are correct if you think that he gave up the flower pots for the toilet. The universal sign for bathrooms may be a barrier to cognitively impaired individuals.) Toilet

Urge Incontinence is… a loss of urine with an abrupt and strong desire to void. “I’m unable to make it to the bathroom on time.” caused by an overactive detrusor muscle, resulting in excessive involuntary bladder contractions that may be initiated by: cancer (bladder / prostate) infection spinal or nerve damage often found in individuals with diabetes, stroke, dementia, Parkinson’s disease, or multiple sclerosis Leakage of urine (usually larger in volume than stress incontinence) because of inability to delay voiding after sensation of bladder fullness is perceived. When they hear or touch running water, open the garage door, put the key in the lock. Detrusor motor &/or sensory instability, isolated or associated with one or more of the following: Local genitourinary condition: cystitis, urethritis, tumors, stones, diverticuli, and outflow obstruction CNS disorders: stroke, dementia, parkinsonism, spinal cord injury or disease

Urge Incontinence: Treatment Behavioral therapy bladder training Electrical Stimulation biofeedback Medications Biofeedback works best with clients in which physiological processes are relevant (Futterman & Shapiro,1986) muscle tension (emg feedback) skin temperature (thermal feedback) brain waves (EEG feedback) respiration

Bladder Retraining treats urge incontinence voiding by the clock “Freeze & Squeeze” OR “Sigh and be Dry” (these actions can help clients get through initial sensations to void that occur more frequently with this kind of incontinence. Not voiding with each urge can retrain the bladder, so that the need to void is increased to every two hours and/or when bladder is actually full.) treats urge incontinence voiding by the clock times set by voiding diary gradually inc voiding interval to 3-4 hours lengthen time pattern with improvement (usually in 15 min. increments, weekly) “Freeze & Squeeze” OR “Sigh and be Dry” until urge passes

Overflow Incontinence loss of urine related to the overdistention of the bladder frequent or constant dribbling may include urge or stress UI causes loss of bladder muscle tone and/or outlet obstruction MS, DM, outflow obstruction (BPH), spinal or nerve damage least common, hard to diagnose treatment review medications drainage: intermittent, continuous Leakage of urine (usually small amounts) resulting from mechanical forces on an overdistended bladder or from other effects of urinary retention on bladder & sphincter function Lose small amounts during day and night Get up often during the night to go to the BR Often feel as if you have to empty your bladder but can’t Pass only a small amount of urine but feel as if your bladder is still partly full Spend a long time at the toilet, but produce only a weak, dribbling stream of urine. Treatment: relief/removal of obstruction, intermittent catheterization program (ICP), medications, Crede, Foley Catheter

When to Refer? marked pelvic prolapse marked prostate enlargement difficulty passing a 14 Fr. catheter most cases of overflow hematuria treatment failures Some causes of UI need further evaluation by a urologist or surgeon. After conservative measure are attempted referrals are often helpful in determining if other measures may be indicated.

Treatment Options for UI behavioral techniques biofeedback scheduled toileting exercise medication surgery continence promoting devices Pessary (read your textbook or search the internet to find out how these help women with incontinence) Potential fixable causes of UI available per MDS were: Medications- antipsychotics, antidepressants, antianxiety hypnotics Congestive Heart Failure, DM, Pedal Edema,Delirium, Depression, Impairments in ADL’s (transfers, ambulation, dressing, toileting, bedrails, restraints) Continence Promotion Devices: Pessary Surgery to suspend bladder post-prostatectomy to avoid the shift of the bladder downward to fill the 2-4cm space left thus causing UI 1 in 4 men suffer UI post prostate surgery Medications: to reduce excessive detrusor muscle contractions (antispasmodics) to stimulate detrusor muscle contractions to regulate detrusor muscle instability (urge UI, anticholinergics, can cause smooth muscle relaxation) “Men don’t assume it’s their fate, so they are more likely to go to a physician. Women are more likely to just go buy some Depends” But in about 80% of cases, treatment could help women.

Management of UI is a team effort Must involve: the client family caregiver(s) nursing primary care provider dietician PT/OT/RT/SLP management Each member of the team has a perspective on the uses, causes and solutions: Client: History of problem, how they have dealt with it Family: History, what have they observed Caregiver(s): What has/has not worked? PCP: Assessments, identify causes, treatments Nursing: voiding record, plan, products PT: client mobility OT: toileting, dressing skills and devices RT: activity program to inc mobility SLP: communication issues Dietician: food & fluid issues Management: supply and personnel resources

Behavioral Interventions are non-invasive involve caregiver and individual measure outcomes are inexpensive are effective are low risk Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women, Burgio,K. et al. Vol.280, pp.1195-2000, Dec 16,1998 Results: Behavioral treatment (biofeedback) yielded a reduction of 80.7% UI Drug Treatment (oxybutynin) 68.5 % reduction Placebo control 39.4% Clients perceived improvement was greatest with behavioral treatment (74.1%) “much better” vs. 50.9% and 26.8 % for drug treatment and placebo Only 14% of the behavioral group wanted to try other treatments, 75% of the other groups wanted to try behavioral approaches.

Unlocking UI: Behavioral Methods assessments food and fluid changes pelvic floor muscle exercises bladder retraining education Refer to assessment form and be sure to assess functional environmental caregiver aspects of UI.

Bladder (Voiding) Record time voiding occurs type/ amount of incontinence presence of urge sensation activity associated with loss of urine daily number of pad changes intake of dietary irritants fluid intake See examples of various forms that can be used to obtain this information for analysis. time voiding occurs type / amount of incontinence large amount - urge small amount- stress presence of urge sensation activity associated with loss of urine daily # of pad changes intake of dietary irritants fluid intake

Example of Voiding Record Refer to various voiding record handouts for examples.

Physical Exam Abdominal/Pelvic/Genitalia/Rectal exam Neurological Status Dexterity Mental Status Mobility See Short Portable Mini-Mental Status Exam 3 minute recall DLROW clock drawing See Geriatric Depression Scale See Get up & Go test ( for mobility screening) Examination for: Abdominal masses, bowel tones, prolapses, infections, impactions etc.

Maintain/Promote Mobility assessments by OT / PT / SLP use of assistive devices walkers, canes exercise programs proper shoes foot care uncluttered walkways Mobility is crucial to the reduction / management of UI. The more mobile and agile an individual is the longer continence can be maintained and and level of dependence on caregivers minimized.

Absorbent Products trial and error evaluate products for... skin irritation noise comfort odor control ease of use/ability to change absorption confidence There is improved success in selection after a thorough assessment Note: with dementia clients remember they often don’t understand what paper products are for; frequently refusing them or ripping them off Try reusable incontinent products

Factors to consider with absorbent products skin integrity comorbidity optimal product for client incidence of vaginitis/ bacteriuria functional disability of client type and severity of UI gender availability of caregivers previous treatment programs client preference Show & Tell of various types of absorbent products.

Mild to Moderate UI Serenity (UI pad) in one study received highest overall performance score Always (menstrual pad) Study found that menstrual products were = to or better than UI products and less expensive (except for Serenity) Refer to Handout on supply catalogs for product information.

Chronic Incontinence scheduled toileting improved access to toilets fluid and diet management absorbent garments/ devices change clothes when wet Absorbent products: Use least expensive, least bulky, most normal product that facilitates independence and dignity and is the easiest for the individual and caregiver Paper products are expensive Try washable products first

Food & Fluids aim for 1500-2000 ml/day avoid bladder irritants include jello, soups, popsicles, water-packed fruits etc. (caution with diabetics) avoid bladder irritants such as caffeine and chocolate avoid evening fluids treat dependent edema elevation during the day compression stockings decrease sodium intake Aim for 1500-2000 ml/day this approximately 6-8 (8oz.) total intake Avoid bladder irritants caffeine ( pop, coffee, tea, chocolate) foods that acidify urine (citrus, carbonated beverages) Avoid evening fluids promotes nocturia Treat dependent edema Congestive Heart Failure (CHF) elevate legs during the day utilize compression stockings

Frequent UTI’s Cranberry juice, 10 oz daily Check fluid intake must have at least 25% cranberry juice Check fluid intake Check post-void residual Change catheter or remove Cranberry juice: does not aggravate UI does not acidify urine highly concentrated acids in cranberries prevent the E.coli bacteria from attaching to the bladder lining can cut UTI’s in 1/2

Dementia can double the incidence of UI inability to dress and/or transfer can increase incidence 13 times one study: 55% of ambulatory dementia clients became dry or had a significant improvement in UI with an individualized scheduled toileting program (Shelly, J. & Flint, A. (1995). Urinary incontinence associated with dementia. Journal of the American Geriatric Society, 43(2), 286.) Dementia can have a significant impact on an individuals ability to maintain continence. However, with caregiver support continence is possible.

UI and Dementia: utilize habit voiding dress in clothing that is easy to remove stay with the client and do not distract try again in 5 minutes if they say,”I just went.” use language that is understood simplify steps involved keep bathroom warm and comfortable Simplify steps: for example, “ Sit down”, perhaps adding a gentle downward touch on the shoulder or a gentle touch behind the knee to give tactile cues to sit down Watch for non-verbal cues: reaching for their belt, tugging at a zipper or taking pants down, and restless behaviors, wandering, agitation Use familiar language: some individuals respond to words used in their past such as;“pee”, “tinkle”, or “take a leak” Listen carefully: the person may use the wrong words, for example “I want tea”, or “take a peek”. No reprimands for accidents, be encouraging, reassure (Robinson,A. et al,1996)

Habit Training voiding at predetermined times goal: to decrease/eliminate number of incontinent episodes (keep dry) fixed time intervals allows for schedule adjustments requires commitment Predetermined times are based on the 3 day voiding diary Fixed time intervals examples: every 2-4 hours individualized related to events (usually mealtimes, get up in am and going to bed)

Caregiver assessment Availability of caregivers? Caregivers have the knowledge they need to manage urinary incontinence? (Schedules, safe transfers, signs/symptoms of UTI) Are caregivers willing to help with continence? Do caregivers have the equipment they need? (such as a gait belt for safe transfers) Availability? enough staff organized Knowledge? know how to complete voiding log what to report to supervisors skills to encourage continence ongoing training/ education Willingness? tries to follow the plan encourage the client Equipment? products, assistive devices, gait belts available

Caregiver frustration educate give lots of positive reinforcement seek their input problem-solve on weekly basis start with one client at a time tap into their creativity Caregivers are often the key to success in any program to eliminate / reduce UI in the older person. Because continence is a hourly, daily issue, continual monitoring, and support is needed to demonstrate the value of continence promoting activities.

To ponder... The bladder is the mirror of the soul. Chinese proverb The meaning of this proverb is up to the individual. But when you really have to go, matters of the soul can become unimportant. When you gotta go nothing else really matters!

Urinary Incontinence was prepared by Catherine Van Son, Ph. D, R. N Urinary Incontinence was prepared by Catherine Van Son, Ph.D, R.N. for the Older Adult Focus Project, OHSU School of Nursing.