Abena urinary incontinence in older people

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The importance of continence assessment in older people.

Older people have a high prevalence of both urinary and faecal incontinence and this is increasing due to the growing number of older people in the population.

Incontinence can have far reaching implications for Katherine Wilkinson MA, those affected, RN, DN, FAE730/7 causing anxiety, shame and embarrassment which can result in older people becoming socially isolated.

Incontinence is also known to be associated with an increased risk of falls in older people and skin problems.

Incontinence can be the last straw for family members caring for an older person, and is often the reason for admission to a care home.

An assessment by a skilled health care professional can enable appropriate treatment to be initiated which may improve or cure the incontinence. Where necessary individually selected containment products can be used to improve dignity and quality of life.

NICE has published guidance for the assessment and management of urinary incontinence in men and women, yet recent audits by the Royal College of Physicians showed that there are still many gaps and shortfalls in the standard of

continence care provided to older people in the UK.

How does the bladder work?

The urinary bladder is a hollow, muscular organ that has two functions, to store urine and to empty when required. Bladder control requires a complex coordination of the bladder muscle (known as the detrusor), urethra, pelvic floor muscles and the nervous system and there is much potential for things to go wrong, which can result in bladder dysfunction and incontinence.

The “normal” bladder can hold approximately 500 mls of urine, and most people will feel the first sensation that they need to pass urine when the bladder is about half full. As the bladder fills, it sends messages via the sensory nerves to the brain. If it is not convenient to pass urine the brain sends an inhibitory message back to the bladder, telling it to “hold on”. When the person has found an appropriate place to void, the brain sends an activating message to the bladder, stimulating the parasympathetic nerves which cause the detrusor muscle to contract and empty the bladder.

Age related changes to the urinary system The bladder and associated structures undergo age related changes which can affect the individual’s bladder function and continence status.

The older person’s bladder is likely to have a reduced capacity and over-activity of the detrusor muscle is common. This can result in increased frequency of urination, urgency and urge incontinence, a condition known as overactive bladder. The detrusor muscle can also become weak, resulting in incomplete bladder emptying (known as a post void residual volume).

In women, due to a decrease in oestrogen levels, atrophic changes take place in the urethra and vagina. This can result in a decreased urethral pressure in women, increasing the likelihood of stress and urge incontinence and also an increased risk of urinary tract infections. The pelvic floor muscles may be affected by ageing due to a decrease in collagen content and a decrease in oestrogen, and also weakened through childbirth, constipation and chronic coughing. This may result in leaking urine on coughing and sneezing, a condition known as stress incontinence In men the risk of benign prostatic hyperplasia (BPH) increases with age which can give rise to a number of symptoms including irritative symptoms such as urgency and frequency, hesitancy and straining and urinary retention.

Microscopic BPH is seen in about 65% of men aged 60-70yrs, 80% of men aged 7080yrs and 90% of men aged 80-90yrs. It is estimated that around 25% of these men will develop bladder symptoms due to outflow obstruction.

Other causes of urinary incontinence in older people The frail older person often has health conditions that can cause bladder and bowel dysfunction. Incontinence in older people is frequently a result of medication that has been prescribed for other conditions.

Older people with chronic chest conditions such as chronic obstructive pulmonary disease (COPD) are at increased risk of stress incontinence due to the strain that coughing puts on to the pelvic floor muscle.

Diabetes Mellitus occurs in 15 – 20% of the frail elderly and can result in a range of bladder problems including polyuria, urinary retention and urinary tract infection.

Older people with heart failure are likely to have an increased urine production at night (nocturnal polyuria) which can result in nocturia and nocturnal enuresis. This can have an impact on quality of life and is also a common cause of falls when trying to reach the bathroom.

Diuretic medication for this condition can cause day time urgency, frequency and incontinence.

Severe constipation is a common problem in older people and faecal impaction can cause both urinary retention and faecal impaction resulting in double incontinence. Constipation is a common problem in older people, often a side effect of medication, and this can put pressure on to the bladder, and also weaken the pelvic floor muscles which can result in stress incontinence. Constipation can result in faecal impaction which can cause urinary retention and incontinence of urine and faeces.

Neurological conditions such as stroke, Multiple Sclerosis and Parkinson’s disease may interfere with the nervous pathways that control bladder function, resulting in urgency and frequency and sometimes retention of urine.

Assessment of older people with urinary incontinence NICE states that older people must have access to a continence assessment undertaken by a suitably trained health professional. A good assessment will identify the cause of the incontinence and enable appropriate treatment to be initiated. Incontinence can often be cured, even in a frail older person, with simple measures.

When assessing the older person with bladder and bowel problems, it is important to respect dignity and privacy, and recognise that the person may be ashamed and embarrassed about losing control of their bodily functions.

At least 45 minutes should be set aside to enable a holistic and comprehensive assessment to be undertaken. It is advisable to use an assessment tool to guide the process and to ensure that all the essential information is gathered and documented.

Before undertaking an assessment a three day bladder diary should be kept, to monitor the fluid intake and type, urine output, frequency and volumes and any incontinent episodes. An accurately completed bladder diary will provide valuable information about the number of voids a day and night, the minimum and maximum volumes voided, the amount and type of fluid taken and the number of incontinent episodes.

Certain fluids can cause urgency and frequency in a sensitive bladder, for example drinks containing caffeine such as coffee and tea, and alcohol. It is also important to drink adequate fluid, usually 1.5 – 2litres a day.

The types of urinary symptoms should be identified, e.g. urinary urgency, stress type urinary leakage, urinary tract infections, nocturia.

A urinalysis undertaken with a multi–property reagent stick can provide valuable information that can lead to a diagnosis or disprove a suspected condition. A urine test can help to identify conditions such as urinary tract infection, diabetes, and bladder stones or tumours.

The medical and surgical history should be taken into consideration and the medication reviewed, checking for potential bladder related side effects.

A portable bladder scan should be used to assess bladder emptying. Many older people do not empty their bladders to completion and this can cause urinary tract infections and urinary frequency and urgency.

If indicated, a vaginal and rectal examination may be performed by a practitioner who is trained and competent. This will identify the strength or weakness of the pelvic floor muscles and also reveal conditions such as prolapse, vaginal atrophy and faecal impaction.

An abdominal examination should be undertaken by the Doctor to exclude an abdominal mass and in men a digital rectal examination to assess the size of the prostate gland. Blood may be taken to measure the PSA (prostate specific antigen) which if raised may be due to prostate cancer.

During the assessment if any “red flag” conditions are identified, the Doctor should be informed and appropriate referral made for further investigations, for example blood in the urine or recurrent urinary tract infections.

Many older people have declining cognitive function, which can worsen when they are moved from their familiar surroundings and admitted to a care home. It is important to establish the person’s ability to recognise the need to pass urine or have their bowels opened, and their ability to find and reach the toilet, and use it independently or have ready access to help when needed.

Plan of care following assessment Following assessment, a working diagnosis can be made and a plan of conservative therapies initiated. Time needs to be spent giving a clear explanation to the individual and / or carer. The options should be discussed with the older person and their willingness and ability to participate in self-help strategies assessed. Their

preferences for care must be established and the care plan individualised with patient centred goals.

Conservative measures such as bladder retraining, prompted voiding, ensuring a good fluid intake and reducing caffeine, constipation management and pelvic floor exercises can all be very effective in promoting continence. In frail elderly people some interventions may not always be appropriate, but advanced age alone should not preclude treatment.

For many older people with intractable incontinence, containment in the form of an incontinence pad or a urinary sheath is necessary. Incontinence pads are available free of charge via the NHS, however there are many inequalities in the level of provision amongst NHS organisations, and an increasing number of elderly people are having to fund the cost of their incontinence products themselves.

Older men with benign prostate disease may have their symptoms managed well with medication and watchful waiting.

Drug therapy in the form of anti-muscurinic medication can relieve the symptoms of overactive bladder but should be prescribed with caution in older people due to the risk of drug interactions with other medications they may be taking, the effect of co-existent disease and also the risk of side effects such as impaired cognitive function.

NICE recommend the use of topical oestrogen for vaginal atrophy and reports that it can also improve symptoms of frequency, dysuria, urge or stress urinary incontinence.

Surgery should only be considered after conservative therapies have been tried. Age is not a barrier to incontinence surgery however the frail elderly are more susceptible to postoperative complications.

Incontinence products should be assessed on an individual basis, taking into account the type and amount of incontinence, skin integrity, mobility, dexterity, cognitive function, gender and availability of care.

Selecting the correct type, size and absorbency of a product is essential if it is to maintain comfort and security. In turn this can improve a patient's quality of life, protect dignity, encourage independence and even promote continence.

Written for Abena UK Limited by: Katherine Wilkinson MA, RN, DN, FAE730/7 February 2013

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