1. Slide 1 Continence And Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long Term Care

2. Slide 2 Session Overview The types of stroke. The types of stroke. The common changes that result from stroke. The common changes that result from stroke. The link between stroke and continence The link between stroke and continence The types of incontinence. The types of incontinence. Strategies to support a resident’s success in being continent. Strategies to support a resident’s success in being continent.

3. Slide 3 What is a Stroke An interruption of the supply of blood and oxygen to an area of the brain. An interruption of the supply of blood and oxygen to an area of the brain. This causes the brain cells in an area to die, and reduces the brain function in that area. This causes the brain cells in an area to die, and reduces the brain function in that area. The area of the body controlled by the damaged area in unable to function properly. The area of the body controlled by the damaged area in unable to function properly. There are two types of stroke. There are two types of stroke. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

4. Slide 4 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can happen when a blood clot blocks a blood vessel in the brain. 80% of strokes are this type.

5. Slide 5 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can also happen when a blood vessel breaks and results in bleeding in the brain. 20% of strokes are this type.

6. Slide 6 Risk factors you can do something about… High blood pressure High blood pressure High blood cholesterol High blood cholesterol Heart disease Heart disease Diabetes Diabetes Being overweight Being overweight Excessive alcohol use Excessive alcohol use Physical inactivity Physical inactivity Smoking Smoking Pearson et.al., (2002) AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases Circulation, 106, 388-391.

7. Slide 7 What does a resident who has had a stroke look like in LTC?

8. Slide 8 What are some of the losses due to stroke? paralysis or weakness on one side of the body; paralysis or weakness on one side of the body; vision problems; vision problems; trouble speaking or understanding language; trouble speaking or understanding language; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

9. Slide 9 What are some of the losses due to stroke? inability to recognize or use familiar objects inability to recognize or use familiar objects tiredness; tiredness; depression; depression; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

10. Slide 10 What are some of the losses due to stroke? exaggerated or inappropriate emotional responses; exaggerated or inappropriate emotional responses; difficulty learning and remembering new information; and difficulty learning and remembering new information; and changes in personality. changes in personality. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

11. Slide 11 Stroke Statistics There are between 40,000 and 50,000 strokes survivors in Canada each year. There are between 40,000 and 50,000 strokes survivors in Canada each year. 10% (4-5,000) of strokes survivors each year require long-term care. 10% (4-5,000) of strokes survivors each year require long-term care. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=news&From=SubCategory

12. Slide 12 Stroke can cause a loss of bowel and bladder control. http://www.medicine.mcgill.ca/Strokengine/module_ui_intro-en.html

13. Slide 13 Urinary Incontinence is common in stroke 40-60% of stroke survivors are incontinent after having their stroke. Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinenceafter stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.

14. Slide 14 Over time bladder continence can improve. Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.

15. Slide 15 There may be improvement in their bladder/bowel function Upon discharge from hospital : 25% of stroke survivors are incontinent 1 year: 15% of stroke survivors are incontinent Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.

16. Slide 16 Types of Incontinence 1. Physical incontinence 2. Functional incontinence

17. Slide 17 Physical Incontinence Urinary Frequency Urinary Frequency Urgency (sudden compelling desire to pass urine which is difficult to defer) Urgency (sudden compelling desire to pass urine which is difficult to defer) Urge Incontinence (involuntary leakage) Urge Incontinence (involuntary leakage) Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.

18. Slide 18 Functional Incontinence Patient has either decreased mental ability or decreased physical ability and is unable to make it to the bathroom in time. Patient has either decreased mental ability or decreased physical ability and is unable to make it to the bathroom in time. Turhan et.al., Impact of stroke etiology, lesion location and aging on post-stroke urinary incontinence as a predictor of functional recovery, International Journal of Rehabilitation Research 2006, Vol 29 No 4

19. Slide 19 To remain continent a resident must… Know they have to void Know they have to void Communicate their need to a caregiver Communicate their need to a caregiver Be motivated Be motivated Brittain et.al., (1998) Stroke and Incontinence, Stroke, 29, 524-528

20. Slide 20 To remain continent a resident must… Be able to Be able to –bear weight –assist in transferring to a toilet or commode –or use an appropriate appliance Delay voiding until the appropriate time Delay voiding until the appropriate time Initiate voiding voluntarily Initiate voiding voluntarily Brittain et.al., (1998) Stroke and Incontinence, Stroke, 29, 524-528

21. Slide 21 Impact of Stroke on Continence Care Inaccurate interpretation of messages and sensations from the brain to the bladder. Inaccurate interpretation of messages and sensations from the brain to the bladder. Decreased thinking abilities (insight, impulse control) Decreased thinking abilities (insight, impulse control) Decreased functional ability Decreased functional ability Brittain et.al., (1998) Stroke and Incontinence, Stroke, 29, 524-528

22. Slide 22 Stroke and Incontinence Link Frequent coughing (difficulty swallowing) Frequent coughing (difficulty swallowing) Problems speaking (aphasia) Problems speaking (aphasia) Brittain et.al., (1998) Stroke and Incontinence, Stroke, 29, 524-528

23. Slide 23 Other Causes of Incontinence Fecal impaction Fecal impaction Drug therapy Drug therapy Diuretics Diuretics Poor diabetes control Poor diabetes control Urinary tract infections Urinary tract infections Low estrogen levels in women Low estrogen levels in women Pre-morbid conditions Pre-morbid conditions Brittain et.al., (1998) Stroke and Incontinence, Stroke, 29, 524-528

24. Slide 24 Incontinence Strategies Use of individualized assessment and goal setting Use of individualized assessment and goal setting (Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.) Scheduled toileting– before/after meals, q2h, and prn (MOHLTC standard) ( Scheduled toileting– before/after meals, q2h, and prn (MOHLTC standard) (Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults. Cochrane Database of Systematic Reviews 2004, Issue 1.) Adequate fluid intake – 1500ml/day (MOHLTC standard) Adequate fluid intake – 1500ml/day (MOHLTC standard) Making sure the resident is close to a washroom Making sure the resident is close to a washroom

25. Slide 25 Incontinence Strategies Adaptable clothing Adaptable clothing Communication – resident can tell you what they need Communication – resident can tell you what they need Adaptive devices – commode, grab bars, use of urinals, bed pans Adaptive devices – commode, grab bars, use of urinals, bed pans

26. Slide 26 Incontinence Strategies Use incontinent products when needed Use incontinent products when needed Encourage independence and self-care Encourage independence and self-care Environment prompting Environment prompting Privacy Privacy Dementia care strategies – responsive behaviour strategies, PIECES Dementia care strategies – responsive behaviour strategies, PIECES

27. Slide 27 Allie Allie has been recently admitted to Cozy Acres with a diagnosis of stroke. This is the first time that you have worked with Allie and have not been able to review her chart. The RN lets you know that Allie is incontinent. Allie is able to walk with assistance but she has fallen before. Allie needs you to help her with washing and getting dressed. Allie needs assistance ambulating to the washroom and removing her clothing. Allie is unable to tell you that she needs to use the toilet, however she is able to accurately report Y/N responses. Allie often identifies when she needs to be changed by moaning or gesturing to staff.

28. Slide 28 Allie What are two possible losses that Allie has experienced as a result of her stroke that may be affecting her incontinence. What can you do about this situation?

29. Slide 29 Next Steps… You are the eyes, ears and voice of your home. You are the eyes, ears and voice of your home. Be aware of the diagnosis of your residents. Be aware of the diagnosis of your residents. Take this stroke information and use it with the residents that you work with. Take this stroke information and use it with the residents that you work with. Share this stroke information and care strategies with other staff. Share this stroke information and care strategies with other staff. Follow-up in 2 months with the home’s best practice champions. Follow-up in 2 months with the home’s best practice champions.

30. Slide 30 More Information Acute Changes and Stroke Acute Changes and Stroke Continence and Stroke Continence and Stroke Dementia and Stroke Dementia and Stroke Falls and Stroke Falls and Stroke Pain and Stroke Pain and Stroke Please contact: Rebecca Fleck or Kim Young Community and Long Term Care Specialist Central South Regional Stroke Program 905-521-2100 x 44127

31. Slide 31 Acknowledgements Best Practices long term care advisory group Best Practices long term care advisory group Best Practices long term care evaluation group Best Practices long term care evaluation group Best Practice Continence Working Group, Haldimand Norfolk Best Practice Continence Working Group, Haldimand Norfolk Charmaine Martin, Hamilton Health Sciences, Acute Care Nurse Practitioner Charmaine Martin, Hamilton Health Sciences, Acute Care Nurse Practitioner Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Central South Regional Stroke Program Central South Regional Stroke Program Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro-ambulatory Centre Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro-ambulatory Centre Melanie Fall Stratton, Regional Stroke Program, Program Manager, Melanie Fall Stratton, Regional Stroke Program, Program Manager, Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Rhonda McNIcoll-Whiteman, Hamilton Health Sciences, Stroke Best Practice Co-ordinator Rhonda McNIcoll-Whiteman, Hamilton Health Sciences, Stroke Best Practice Co-ordinator Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator

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