Best Nursing Practices in Care for Older Adults ELDER Project Fairfield University School of Nursing Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Session 7 Topic: Urinary Continence of Older Adults Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Definition of Urinary Incontinence (UI): An involuntary loss of urine sufficient to be a problem to an older adult. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Prevalence of Urinary Incontinence: Millions of Americans have urinary incontinence (over 7 million) 15-30% of non-institutionalized older adults 50% or more of nursing home residents (30% of these people have fecal incontinence as well) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Reporting Urinary Incontinence UI is underreported, under diagnosed, and therefore under treated. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Is Urinary Incontinence a Normal Part of Aging? Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Answer: No! Age alone does not cause urinary leakage Prevalence increases with age due to the normal aging processes such as muscle loss A loss of estrogen in females may contribute to UI It is one of the leading risk factors for institutionalization Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Bladder Control: Maintaining bladder control requires Input from central nervous system Integrity of lower urinary tract function Effective mentation Mobility, motivation, and manual dexterity Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Direct Costs of Incontinence: Annual costs: Billions of dollars spent on equipment, and yearly for both community dwelling adults and for those in Long Term Care Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Risk Factors Associated with Urinary Incontinence: Immobility, Environmental Barriers Impaired cognition, Delirium Medications Morbid Obesity, Smoking Fecal Impaction Diabetes, Stroke, Estrogen Depletion Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Risk Factors Continued: High Impact Physical Activities Childhood enuresis Caffeine or Alcohol Diuretic effect leads to bladder irritation Low Fluid Intake Leads to bladder irritation, and urgency Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Transient Incontinence Pneumonic: DIAPPERS D: delirium I: infection A: atrophic urethritis/vaginitis P: pharmaceuticals P: psychological E: excess excretion R: restricted mobility, or restraints S: stool Impaction Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

5 Major Types of Urinary Incontinence Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 # 1: Urge Incontinence One of the most common types of incontinence Associated with a strong urge to void Overactive detrusor muscle causes excessive involuntary bladder contraction Associated with neurological conditions Stroke Spinal cord injury Multiple Sclerosis Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

# 2: Stress Incontinence Also one of the most common types of incontinence Associated with actions that increase intra-abdominal pressure Coughing & Sneezing Bending & Lifting Laughing Cause is pelvic muscular weakness or urethral hypermotility Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

# 3: Overflow Incontinence Occurs when the bladder is over distended May have stress or urge symptoms as well Cause: Low tone bladder muscle Obstruction to bladder outlet or urethra Overly full bladder Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Over Flow Incontinence Continued: May be associated with certain conditions: Drug side effects Radical pelvic surgery Diabetic neuropathy Low spinal cord injury Benign prostatic hyperplasia (BPH) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

# 4: Functional Incontinence Physical or psychological impairment affects continence There is a competent urinary system Causes Bathroom is too far away Slow gait Difficulty removing clothing in time Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

# 5: Reflex Incontinence Loss of urine without warning or sensory awareness Causes: Spinal cord injury Radical pelvic surgery Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Assessment Options for Urinary Incontinence Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Assessment: Take a Good History: Ask about medications that may contribute How often are they incontinent How much urine do they leak Do they have a severe urge to go right away Do they use a pad or diaper Is the incontinence worse during the day or night Do they use caffeinated beverages, and how much What is their fluid intake on a normal day How far away is the bathroom Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Make a Referral Based on Your Assessment: If the patient exhibits true incontinence, refer to: Urologist Gynecologist Urinary incontinence nurse Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Bedside Cystometrogram Bedside cystometrogram can be used to assess bladder function: how well the bladder stores and releases urine Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Treatment Options for Urinary Incontinence: Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Which Treatment Option Is Best? Must be individualized for each person Behavioral Therapies Pharmacological Treatments Surgical Treatments Equipment and Devices Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Enabling Good Toileting Habits The closer the patient is to the bathroom, and the easier it is for them to use the toilet, the less likely they are to be incontinent This is absolutely key to prevention! Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Behavioral Therapies Scheduled toileting (every 2-3 hours) Bladder training (holding urine for progressively longer intervals) Habit training (ex: varied urine volumes due to a diuretic) Kegel exercises (pelvic muscle contractions) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Behavior Therapies Continued Avoidance of bladder irritants (caffeine, alcohol, nutrisweet) Hydration (1/2 the body weight in pounds is the number of ounces of liquid needed per day) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Another Non-Pharmacologic Strategy: Electronic Stimulation: Electrodes are placed in the vagina, anus or on skin surface Electrical current is applied to the sacral area This will inhibit over activity of the bladder Improves pelvic muscle contractions Rarely done Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Pharmacologic Treatments It is important to remember that older adults may be more prone to side effects of many drugs Drugs should be used with caution, and avoided if at all possible! Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Drugs for Urge Incontinence Anticholinergics: ex: Oxybutynin Action: antispasmotic, analgesic to smooth muscle Metabolized by the liver Side effects: constipation, dry mouth, confusion, urinary retention Contraindications: with glaucoma, colitis, urinary retention Tends not to work all that well Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Drugs for Stress Incontinence: Alpha-adregnergic agent: ex:pseudophedrine Action: stimulates alpha fibers at bladder neck and at sphinctor, which increase tone Side effects: HTN, insomnia, tremor, agitation Contraindications: HTN, glaucoma, not for those on MAO inhibitors * Caution with older adults! Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

More on Stress Incontinence Hormone replacement therapy: low dose Premarin Cream topically Action: reduces irritation from vaginitis Side effects: may cause spotting, sore breasts, cardiovascular risk factors with estrogen Controversy over safety of estrogen replacement Contraindications: endometrial, ovarian, or breast cancer Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Drugs for Overflow Incontinence Anti-adrenergic: ex: Prazosin (Minipress) Action: decreases symptoms for prostatic hyperplasia (urgency, hesitancy, nocturia) Excreted mostly by the liver Side effects: dizziness, headache, weakness, syncope, orthostatic hypotension, palpitations Contraindications: renal insufficiency, angina, liver disease Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Drugs for Bladder Spasms: Antispasticity Agents: ex: Baclofen Action: inhibits reflexes at spinal level May improve bladder & bowel function Side effects: dizziness, drowsiness, fatigue, confusion, depression, nausea, urinary frequency, hyperglycemia Contraindications: epilepsy, increased CNS side effects with elderly patients, renal impairment Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Surgical Treatments The following are rarely used for incontinence: Artificial urinary sphincters to improve sphincter function or dilation of a urethral stricture Prostatectomy or Transurethral resection of the prostate (TURP) Circumcision, Penile reconstruction Urinary Diversion or Suprapubic Catheter Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

To Catheterize or Not to Catheterize Whenever possible, it is best to avoid catheterization as a strategy against incontinence! Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Appropriate and Inappropriate Use of Indwelling Catheters Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Indwelling Catheters are Indicated for: Monitoring of acutely ill patients Managing terminally or severely ill patients Urinary retention not manageable by other means Management of urinary incontinence in people with Stage III or IV pressure ulcers Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Indwelling Catheters are Contraindicated for: Management of incontinence not associated with full thickness pressure ulcers Urinary retention that can be managed in another way Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Risks of Indwelling Catheters: Urinary tract infections and Bacteruria Trauma to Urethra, Urethritis & Urethral Erosions, and fistulas Stones and Obstruction Pain, Discomfort, and Embarrassment Hematuria Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Intermittent Catheterization: A better alternative than a long term indwelling catheter Best used with obstructions that cause overflow incontinence Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Other Equipment and Devices: Absorbent Products: Diapers, briefs, pads Cone shaped absorbents for men Reinforced fit undergarments Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Skin Care: Non alcohol based cleansers Waterproof barriers Vaseline A & D ointment Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Devices: Male or female urinals for immobilized patients Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 External Catheters Condom catheters for male patients Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Reference The content covered in this presentation is provided by the John A. Hartford Foundation Institute for Geriatric Nursing (2001) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858 Reference: Some of the material in this presentation obtained from graciously shared by: Mather’s LifeWays, 2003 Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858

Power Point Presentation Created by: Diana R. Mager, CRN, MSN Fairfield University School of Nursing ELDER Project Director Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858