1. 老人尿失禁的照護技巧 The Techniques of Caring the Aging with Urinary Incontinence 王炯珵 恩主公醫院泌尿科 Chung Cheng Wang Department of Urology En Chu Kong Hospital

2. State of the Science on Urinary Incontinence Nurses have in their toolboxes some help for first-line UI intervention and screening [Diane Newman, 2002 July] The first priority is to increase awareness among nurses. [Mary Palmer, 2003AJN] Noninvasive behavioral interventions can be effective in long-term care setting But staff compliance was problematic [Palmer MH 1997]

3. Epidemiology 20 million American have UI [Abram P 2002] 22% of women aged 65 and older had UI in daily life [Tseng 2000] More than 50% of nursing home residents [Fantl J,1996]

4. Differences in Gender Female: male = 2:1 [Hunskaar S 2001] stress or mixed UI: female Pure urge UI: equal Postvoid dribbling, nocturnal enuresis: male [Temml C 2000] Women were more likely to regularly use strategies for UI management [Johnson TM 2000]

5. Risk Factors in Women Gravidity and parity One vaginal birth: 2.5 times for UI [Nygaard IE 1994] Breech presentation, use of forceps, tearing, central episiotomy, oxytocin Pelvic organ prolapse Gynecologic surgery Menopause Obesity [Roe B 1999]

6. Risk Factors in Men A history of radical or transurethral prostatectomy [Umlauf 1996] The first year of admission to a long-term care facility [Palmer MH 1991] Causes of urge UI in elderly men: UTI, prostate inflammation, bowel dysfunction [Herzog AR 1990]

7. UI in the Frail Elderly Frail: decline in physical activity [Bortx WM 2002] Frail elderly: >65, UI, can not go out without assistance, dementia, admitted to a long-term care facility [Fonda D 1998]

8. Risk Factors in Frail Elderly Multiple medical morbidities Immobility Cognitive impairment (dementia)

9. Screening Routine assessment for UI can be easily incorporated into the general history questions [Feneley RC BJU 1997] Screening by risk factors Urge UI + Nocturia >2 + daytime voiding frequency of < 2hr = 90% detrusor overactivity on UDS [Gray M, 2001]

10. Assessment of UI in the Frail Older Adult History and symptom assessment Clinical and physical assessment Environmental assessment Identify possible diagnosis or clinical impression

11. Potential Reverse Causes Delirium, dementia, depression Infection (UTI) Atrophic vaginitis Pharmaceuticals Psychological, Pain Excess fluid (polyuria, edema) Restricted mobility Stool (constipation)

12. Behavioral Therapy AHCPR guideline Bladder training: strongly recommended for urge and mixed incontinence and also recommended for stress UI Pelvic floor rehabilitation: strongly recommended for stress UI The first line of treatment [Fantl J 1996]

13. Nonpharmacologic Management of UI in Adults Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive interventions

14. Lifestyle Modification Reduce risk factors Stress UI: smoking cessation,change body position [Norton PA 1994], weight reduction [Deitel M 1988] Constipation: good bowel hygiene Urge UI: caffeine reduction, selected dietary and fluid modification No study support: bladder irritants, alcohol [Wyman JF 2000]

15. Nonpharmacologic Management of UI in Adults Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Devices Supportive intervention

16. Scheduled Voiding Regimens Timed voiding Habit retraining Patterned urge response toileting Prompted voiding Bladder training

17. Nonpharmacologic Management of UI in Adults Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive intervention

18. Pelvic Floor Muscle Rehabilitation Pelvic floor muscle exercise Vaginal weight training Biofeedback Electric stimulation Magnetic stimulation

19. Nonpharmacologic Management of UI in Adults Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive intervention

20. Anti-incontinence Device Intravaginal support device External occlusive device Intraurethral occlusive device Complex valved catheter External collection device Urethral catheter

21. Intravaginal Support Device Pessary Support the bladder neck, relieve minor pelvic prolapse and change pressure transmission Stress UI Estrogen replacement for postmenopausal women

22. External Occlusive Device A small single-use device that covers the urethral meatus for women A penile clamp for men Need good manual dexterity Complication: periurethral irritation or penile erosion

23. Intraurethral Occlusive Device Urethral plug A small single-use device that is worn in the urethra to provide mechanical obstruction Used for stress UI in cognitively intact patient Complication: urethral irritation, hematuria, UTI or migrate into bladder

24. Complex Valved Catheter Intraurethral occlusive device with a unidirectional valve Left indwelling for long period Must be inserted and removed by a clinician Being test for female stress UI, overflow UI Complication: urethral irritation, hematuria, UTI

25. External Collection Device Condom catheter with leg bag Used in men with urge, stress and overflow UI and in those with functionally impairment More comfortable, less painful and less restrictive than use of an indwelling catheter [Saint S 1999] Risk for UTI, penile skin marceration

26. Urethral Catheters Disposable, single-use catheter and indwelling catheters Used for overflow UI Bedbound, mobility impairment and severe UI Clean intermittent catheterization is the standard care of spinal cord injury [Perrouin-Verbe B 1995]

27. Indications for Long-term Indwelling Catheters Persistent overflow UI, symptomatic UTI or kidney disease Surgical or pharmacologic intervention failed Contraindication for CIC Changes of bedding, clothing and absorbent products may be painful or disruptive for p’t with an irreversible medical condition Not healed grade 3-4 pressure ulcers Patients live alone without a caregiver

28. Nonpharmacologic Management of UI in Adults Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive intervention

29. Supportive Interventions Toileting substitutes and other environmental modifications Physical and occupational therapy Absorbent products

30. Toileting Substitutes and Other Environmental Modifications Urinals, bedside commodes, elevated toilet seats Used for patients with mobility impairment that make it difficult to reach a toilet in a timely fashion

31. Physical and Occupational Therapy Gait and strength training Used for frail older patients with mobility or manual dexterity impairments that make it difficult to reach a toilet and disrobe in a timely fashion

32. Absorbent Products Absorbent Products Reusable and disposable pads and pants system Some products contain a polymer that absorbs urine and binds with urine, changing it into gel [Newman D 2002] Used for all types of incontinence But never be used solely for the convenience of the caregiver

33. Behavioral Therapy in Frail Elders Adequate fluid intake Bowel regularity Perineal hygiene Voiding every 2 to 4 hours Avoid caffeine in urge UI Toileting programs

34. Skin Care Perineal hygiene after toileting Skin dryness Comfortable clothes Skin ulcer: isolation cream, Duoderm, Comfeel

35. Prevention of Excess Disability The two primary risk factors for UI among the frail elderly are immobility and cognitive impairment Tailored programs that enhance physical mobility and cognitive function [Schnelle J 2000] Optimal management of acute and chronic illness Environmental modification Prosthetic support [Weindrug R 1991]

36. Algorithm -- I Three-day bladder record, measure RU Determine which type of UI What trigger it Individual care plans Four goals: fewer incontinence episodes, daytime continence, 24-hour continence, the prevention of skin breakdown and odor

37. Algorithm -- II Behavioral interventions Ambulatory assistance Cognitively intact  PFM training Passive exercise Goal one to goal three Goal four is reserved for comatose or very debilitated patients