1. Best Nursing Practices in Care for Older Adults
ELDER Project
Fairfield University School of Nursing
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2. Session 7 Topic: Urinary Continence of Older Adults
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3. Definition of Urinary Incontinence (UI):
An involuntary loss of urine sufficient to be a problem to an older adult.
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4. 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)
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5. Reporting Urinary Incontinence
UI is underreported, under diagnosed, and therefore under treated.
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6. Is Urinary Incontinence a Normal Part of Aging?
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7. 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
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8. 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
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9. 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
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10. Risk Factors Associated with Urinary Incontinence:
Immobility, Environmental Barriers
Impaired cognition, Delirium
Medications
Morbid Obesity, Smoking
Fecal Impaction
Diabetes, Stroke, Estrogen Depletion
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11. 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
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12. 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
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13. 5 Major Types of Urinary Incontinence
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14. 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
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15. # 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
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16. # 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
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17. 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)
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18. # 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
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19. # 5: Reflex Incontinence
Loss of urine without warning or sensory awareness
Causes:
Spinal cord injury
Radical pelvic surgery
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20. Assessment Options for Urinary Incontinence
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21. 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
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22. Make a Referral Based on Your Assessment:
If the patient exhibits true incontinence, refer to:
Urologist
Gynecologist
Urinary incontinence nurse
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23. Bedside Cystometrogram
Bedside cystometrogram can be used to assess bladder function: how well the bladder stores and releases urine
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24. Treatment Options for Urinary Incontinence:
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25. Which Treatment Option Is Best?
Must be individualized for each person
Behavioral Therapies
Pharmacological Treatments
Surgical Treatments
Equipment and Devices
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26. 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!
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27. 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)
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28. 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)
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29. 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
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30. 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!
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31. 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
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32. 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!
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33. 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
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34. 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
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35. 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
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36. 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
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37. To Catheterize or Not to Catheterize
Whenever possible, it is best to avoid catheterization as a strategy against incontinence!
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38. Appropriate and Inappropriate Use of Indwelling Catheters
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39. 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
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40. Indwelling Catheters are Contraindicated for:
Management of incontinence not associated with full thickness pressure ulcers
Urinary retention that can be managed in another way
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41. 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
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42. Intermittent Catheterization:
A better alternative than a long term indwelling catheter
Best used with obstructions that cause overflow incontinence
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43. Other Equipment and Devices:
Absorbent Products:
Diapers, briefs, pads
Cone shaped absorbents for men
Reinforced fit undergarments
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44. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858
Skin Care:
Non alcohol based cleansers
Waterproof barriers
Vaseline
A & D ointment
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45. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858
Devices:
Male or female urinals for immobilized patients
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46. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant#D62HP06858
External Catheters
Condom catheters for male patients
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47. Reference The content covered in this presentation is provided by the
John A. Hartford Foundation Institute for Geriatric Nursing
(2001)
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48. 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
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49. Power Point Presentation Created by:
Diana R. Mager, CRN, MSN
Fairfield University School of Nursing
ELDER Project Director
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