Download Chapter 15: Management of Dementia

Chapter 15:
Urinary Incontinence
Learning Objectives
• Describe the prevalence of urinary incontinence
among older adults in community, acute care, and
long-term care settings.
• Identify the negative social, psychological,
physical, and economic implications of urinary
incontinence.
• Understand that urinary incontinence is not a
normal part of aging.
Learning Objectives (cont’d)
• Collect the appropriate data related to patients’
urine control and plan evidence-based nursing
care accordingly.
• Initiate evidence-based behavioral
interventions to treat urinary incontinence and
promote continence for those at risk for urinary
incontinence.
Prevalence
• Estimates vary widely due to differences in
definition, population studied, sampling
approaches, and data collection methods
– Total population with UI: 10%
– Long-term care residents: up to 70%
• Older women: 30% - 50%
• Older men: 9% - 28%
• Not normal consequence of aging but some
physiological changes of aging increase risk of UI
and some conditions that predispose UI occur
more in older persons
Implications of Urinary Incontinence
• Physical
– Incontinence is associated with an increased risk
of falls, fractures, skin breakdown, UTIs, disrupted
sleep
• Psychological (Figure 15-1, p. 548)
– Depression and anxiety both cause and
consequence
– Feelings of loss of control, dependency, shame and
guilt, impaired self esteem
– Majority of UI people do not seek help because
they consider it a normal part of aging
Implications of Urinary Incontinence
(cont’d)
• Social
– Social isolation, avoidance of activities
• Economic
– Costs not covered by insurance
– Direct costs of UI: $16 billion/year
– Costs to nursing homes: $5.2 billion/year
• Estimated 3% - 8% of nursing home costs and 1hr
labor per day go to incontinence care
• Plus costs of medical effects like falls, fractures,
pressure ulcers
Assessment
• Transient Urinary Incontinence
– caused by onset of an acute problem and
should resolve once problem is successfully
treated (P.551, Table 15-2).
• Established Urinary Incontinence
–
–
–
–
–
Stress UI
Urge UI
Overflow UI
Functional UI
Mixed UI
• Stress incontinence: involuntary loss of urine
during activities that increase intra-abdominal
pressure (Triggered by laughing, sneezing,
coughing or straining of abdominal muscles)
– Absence of bladder contraction or over-distention.
– Related to pregnancy, obesity, surgery, exercise,
medications
– Small amounts urine lost
– Occasional or continual episodes of incontinence
– Treatment: biofeedback, Kegel exercise.
• Urge incontinence: a strong, abrupt desire
to void and the inability to inhibit leakage
in time to reach a toilet.
– Related to birth defects, spine or nerve damage,
immobility, prostate problems or cancer
– Moderate to large amounts of urine lost
– Occasional or situational episodes of
incontinence
– Increase risk of falls
– Treatment: Kegels
• Overflow incontinence: overdistention of
the bladder due to abnormal emptying.
– Related to birth defects, spine or nerve damage,
MS, loss of bladder muscle tone, surgery,
medications
– No warning prior to incontinent episode
– Small to moderate amount of urine lost
– Frequent or continual incontinence
– Treatment: treat cause, intermittent cath,
bladder scans for post-void residuals
• Functional incontinence: refers to
problems from factors external to the lower
urinary tract such as cognitive
impairments, obesity, clutter, immobility,
or environmental barriers.
– Related to inability to get to bathroom facilities
due to functional reasons
– May be associated with urge incontinence
(mixed incontinence)
– Treatment: modify environment; modify
lifestyle
• Mixed incontinence:
• Clinically, patients may exhibit symptoms of
more than one type of incontinence.
• Pure stress and pure urge incontinence were
uncommon in a urodynamic evaluation of
people age 65 years or older.
Assessment (cont’d)
• Data Gathering
–
–
–
–
History and other pertinent data
Bladder diary (Figure 15-2, P. 554)
UI Interview Instruments (Table 15-4, p. 555)
Cognitive status
• Physical Assessment
General
Hydration
Genitourinary
Rectal
Abdominal
Bladder Volume
Urinalysis
Environment
Interventions and Care Strategies
• Patient-Centered Urinary Incontinence
Treatment Goals
– Understanding the patient’s expectations for
treatment outcomes will provide direction for
intervention
– Patient goals are multidimensional; don't
necessarily require total continence for
patient satisfaction and improved healthrelated quality of life
Interventions and Care Strategies
• Behavioral Management
– Prompted voiding (Table 15-7, p. 565): for
the physically & cognitively impaired people.
– Bladder training (Table 15-8, p. 566): for the
physically & cognitively independent people.
– Pelvic muscle rehabilitation: “draw in” and
“lift up” the rectal/anal sphincter muscles.
Lift up the perivaginal muscles and avoid
contracting the abdominal muscles. 10
repetitions 2~3 x /day (P. 568)
Interventions and Care Strategies
(cont’d)
• Pharmacological Management (Table 15-9):
Oxybutynin, Imipramine, Tamsulosin…
– Can add to the effectiveness of behavioral
strategies in frail older persons with urge UI
– Potential for adverse reactions
– Added cost
• Devices and products
– Continence garments
– Toileting equipment and collection devices
Interventions and Care Strategies
(cont’d)
• Skin care
– Preventing skin breakdown is very important
– Moisture barriers
– Moisture barriers & no-rinse incontinence
cleansers recommended over soap and water
– Incontinence-associated dermatitis (IAD)
• Increases risk of pressure ulcers
Interventions and Care Strategies
(cont’d)
• Environmental Intervention
– Modifying environment to allow rapid access to
the toilet
• Indwelling urinary catheters
– No longer primary means of managing UI
– Centers for Medicare and Medicaid Services
(CMS) developed regulations for guidance of
long-term indwelling catheter use. (Table 1510, p. 574)
Summary
• Urinary incontinence
– is a serious, potentially disabling condition with
negative social, physical, psychological, and
economic impacts
– is a common condition in the older population,
but is not a part of the normal aging process
– can be successfully treated for improved
health-related quality of life