Geriatric Nursing and Urinary Incontinence

Geriatric Nursing and Urinary Incontinence Introduction

Urinary incontinence (UI) is a prevalent health issue among older adults, significantly affecting their quality of life, physical health, and psychosocial well-being. Despite existing evidence supporting effective management strategies for UI, it is often inadequately addressed in clinical practice. Instead, containment strategies, such as using adult briefs and absorbent products, are frequently employed. This approach reflects a lack of understanding or the stigma associated with UI, contributing to the perception that UI is a normal part of aging (Bush, Castelluci, & Phillips, 2001; Milne, 2000). Nurses play a crucial role in the identification, assessment, and management of UI, and the development of appropriate interventions can significantly improve patient outcomes.

Background and Statement of the Problem

UI affects more than 17 million adults in the United States and is defined as the involuntary loss of urine sufficient to be a problem (Fantl et al., 1996; Resnick & Ouslander, 1990). Prevalence rates for UI among community-dwelling older adults range from 8% to 46%, while rates are higher among those with dementia (11% to 90%) and institutionalized older adults (Brandeis et al., 1997; Du Moulin et al., 2008). UI also affects 10% to 42% of older adults admitted to acute care settings, and 12% to 36% of hospitalized older adults develop acute UI (Palmer et al., 2002).

UI is associated with various negative health outcomes, including falls, fractures, skin infections, pressure ulcers, and psychological distress (Bogner et al., 2002). It is also a predictor of frailty and increased mortality among older adults hospitalized for acute conditions (Holroyd-Leduc et al., 2004). Moreover, UI imposes significant economic burdens, with total direct costs estimated to exceed $16 billion annually in the United States (Landefeld et al., 2008). Given these consequences, nurses must proactively identify, assess, and manage UI in older adults.

Assessment of Urinary Incontinence

Assessment of UI involves evaluating the type, frequency, and severity of incontinence, identifying potential contributing factors, and developing a tailored care plan. Accurate assessment is critical for determining the appropriate interventions and improving health outcomes.

Key Parameters for Assessing UI:

1. Patient History:
   • Obtain a comprehensive history of the patient’s urinary patterns, including frequency, volume, urgency, and nocturia. Assess the onset and duration of symptoms and any precipitating factors.
   • Ask about the impact of UI on daily activities, quality of life, and psychological well-being. Evaluate any previous treatments and their outcomes.
2. Physical Examination:
   • Perform a focused physical examination to assess the lower urinary tract, including checking for bladder distention and palpating for tenderness. Examine for signs of pelvic organ prolapse or rectal impaction.
   • Evaluate mobility, cognitive function, and dexterity, which may impact the patient’s ability to manage toileting independently.
3. Diagnostic Tests:
   • Conduct urinalysis to rule out urinary tract infections (UTIs) and assess for hematuria or other abnormalities.
   • Consider urodynamic studies, bladder diary, or post-void residual measurement if indicated, particularly in complex cases or when initial treatments are ineffective.

Etiologies of Urinary Incontinence

UI is a complex condition influenced by various anatomical, physiological, psychological, and cultural factors (Gray, 2000). The ability to maintain continence depends on intact lower urinary tract function, cognitive and functional ability, motivation, and an environment that supports toileting (Jirovec, Brink, & Wells, 1988). UI can be categorized into two main types: transient (acute/reversible) and established (chronic/persistent).

1. Transient Urinary Incontinence:

• Characteristics: Transient UI is characterized by sudden onset and potentially reversible symptoms. It may be caused by delirium, infections (e.g., untreated UTI), atrophic vaginitis, pharmaceuticals, psychological disorders, excessive urine production, restricted mobility, and stool impaction (Newman & Wein, 2009).
• Management: Identifying and treating the underlying cause is essential. For example, UI caused by a UTI may resolve with appropriate antibiotic treatment, while UI due to diuretic therapy may improve with dosage adjustment (Ding & Jayaratnam, 1994).

2. Established Urinary Incontinence:

• Types and Characteristics:
  • Stress UI: Involuntary loss of urine associated with increased intra-abdominal pressure, such as during coughing, sneezing, or physical exertion. It is more common in women but may also occur in men post-prostatectomy (Abrams et al., 2003).
  • Urge UI: Involuntary urine loss due to a sudden, strong urge to void, often associated with urinary frequency, nocturia, and enuresis. Commonly seen in older adults due to changes in bladder function (Holroyd-Leduc et al., 2008).
  • Mixed UI: A combination of stress and urge UI, characterized by symptoms of both types.
  • Overflow UI: Involuntary urine loss due to bladder overdistension, often resulting from an underactive detrusor muscle or outlet obstruction (e.g., BPH). Patients may present with dribbling, urinary retention, and a sensation of fullness in the lower abdomen (Abrams et al., 2003).
  • Functional UI: Incontinence resulting from non-genitourinary factors such as cognitive or physical impairments, environmental barriers, or acute illness (Fantl et al., 1996).

Interventions and Care Strategies

Nursing interventions for UI focus on identifying the type of incontinence, determining the underlying causes, and implementing individualized care strategies to manage and prevent UI.

1. Treating Transient and Functional Causes of UI:

• Identify and Treat Underlying Causes: Address medical conditions that may contribute to transient UI, such as UTIs, constipation, or mobility limitations. Adjust medications that may exacerbate incontinence, such as diuretics or anticholinergics.
• Promote Mobility and Toileting Assistance: Ensure access to toileting facilities and provide mobility aids or assistance as needed. Implement scheduled toileting or prompted voiding for patients with cognitive impairments.

2. Healthy Bladder Behavior Skills:

• Encourage Fluid Management: Educate patients on maintaining adequate hydration while avoiding excessive fluid intake, particularly before bedtime. Advise against caffeine and alcohol consumption, which may irritate the bladder.
• Bladder Training: Implement bladder training programs that involve gradually increasing the time between voids to improve bladder capacity and control.
• Pelvic Floor Muscle Exercises: Teach patients pelvic floor muscle exercises (e.g., Kegel exercises) to strengthen the muscles supporting the bladder and urethra, particularly for those with stress UI.

3. Additional Nursing Interventions:

• Skin Care and Infection Prevention: Maintain skin integrity by keeping the perineal area clean and dry. Use barrier creams to protect against moisture-associated skin damage. Monitor for signs of UTIs and provide appropriate interventions.
• Education and Support: Provide education to patients and caregivers about UI, its causes, and management strategies. Encourage open communication about UI and reduce the stigma associated with the condition.
• Use of Assistive Devices: Offer assistive devices such as bedside commodes, urinals, or absorbent products as needed. Encourage the use of clothing that is easy to remove to facilitate timely toileting.
• Environmental Modifications: Ensure that the environment is conducive to safe and prompt toileting. Provide adequate lighting, clear pathways, and handrails to reduce the risk of falls and promote independence.

Healthy Bladder Behavior Skills

Developing healthy bladder behavior skills is a key component of managing UI in older adults. Nurses can play a pivotal role in teaching these skills and supporting their implementation.

Key Components of Healthy Bladder Behavior Skills:

• Fluid Management: Encourage patients to maintain adequate hydration without excessive fluid intake. Educate them on avoiding bladder irritants such as caffeine and alcohol.
• Scheduled Voiding: Implement scheduled voiding programs to help patients establish regular toileting routines and prevent accidents.
• Pelvic Floor Muscle Exercises: Teach patients exercises to strengthen the pelvic floor muscles, which can help control bladder function, particularly in those with stress UI.

Additional Nursing Interventions

Nurses can employ various interventions to support older adults with UI and improve their quality of life.

Key Additional Interventions:

• Skin Care and Hygiene: Focus on maintaining skin integrity by keeping the perineal area clean and dry. Use barrier creams to protect against skin damage from moisture and urine.
• Infection Prevention: Monitor for signs of UTIs and provide appropriate interventions promptly.
• Education and Support: Provide education to patients and caregivers about UI, its causes, and management strategies. Encourage open communication about UI and reduce the stigma associated with the condition.
• Use of Assistive Devices: Offer assistive devices such as bedside commodes, urinals, or absorbent products as needed. Encourage the use of clothing that is easy to remove to facilitate timely toileting.
• Environmental Modifications: Ensure that the environment is conducive to safe and prompt toileting. Provide adequate lighting, clear pathways, and handrails to reduce the risk of falls and promote independence.

Introduction

Nurse continence experts emphasize that entry-level nurses should be proficient in collecting and organizing data surrounding urine control and implementing nursing interventions to promote continence (Jirovec, Wyman, & Wells, 1998). Nurses play a critical role in assessing and managing urinary incontinence (UI) in hospitalized older adults, requiring a comprehensive approach to identify the type of UI and develop tailored interventions. Collaboration with an interdisciplinary healthcare team is essential for effective management. This chapter outlines the key assessment parameters and strategies for managing UI in older adults.

Urinary Incontinence (UI) and Patient History

A comprehensive assessment begins with obtaining a thorough patient history. When a patient is admitted to the hospital, the nursing history should include questions to determine if the individual has preexisting UI or risk factors for UI. The nurse should be vigilant for UI-associated risk factors specific to the hospital setting, including depression, malnourishment, dependency in ambulation, long-term care residency, confusion, and demographic factors such as being an African American woman (Kresevic, 1997; Palmer et al., 2002).

Screening should include questions like, “Have you ever leaked urine?” and “If yes, how much does it bother you?” These questions help identify patients who may have undiagnosed or underreported UI. Various instruments are available for assessing UI, such as the Urinary Distress Inventory-6 (UDI-6) for females and the Male Urinary Distress Inventory (MUDI) for males. These tools are reliable and valid for identifying the type of established UI in community-dwelling adults (Lemack & Zimmer, 1999; Uebersax et al., 1995).

Historical questions should focus on the characteristics of UI, including the time of onset, frequency, severity, and possible precipitants such as coughing, urgency, or acute illness. Additionally, nurses should inquire about lower urinary tract symptoms like nocturia, hematuria, and urinary frequency, which can provide clues about bladder dysfunction or other underlying conditions (DuBeau et al., 2010).

Comprehensive Assessment

A comprehensive assessment of UI should include a review of medications, as various medications can adversely affect continence. Commonly implicated medications include diuretics, which cause polyuria, frequency, and urgency, and those with anticholinergic properties, which may cause urinary retention and stool impaction (Newman & Wein, 2009). Psychotropic medications, such as tricyclic antidepressants, antipsychotics, and sedative-hypnotics, can also negatively affect bladder control by contributing to immobility, sedation, and delirium.

Nurses should document all over-the-counter (OTC), herbal, and prescription medications upon admission and monitor for new medications that could contribute to UI. When a patient develops transient UI during hospitalization, the nurse should consider whether a new medication might be affecting bladder control and consult with the prescribing practitioner to determine if the medication can be discontinued or modified.

Key Components of a Comprehensive Examination:

1. Abdominal Examination:
   • Assess for suprapubic distention indicative of urinary retention. Palpation of the bladder can help detect overdistension.
2. Genital Examination:
   • Conduct inspection during routine care (e.g., bathing) to assess for signs of perineal irritation, lesions, or discharge.
   • In women, a Valsalva maneuver (bearing down) or voluntary cough may reveal pelvic organ prolapse (e.g., cystocele, rectocele, uterine prolapse) or stress UI.
3. Digital Rectal Examination:
   • This helps identify transient causes of UI, such as constipation or fecal impaction, and checks for the “anal wink,” which indicates intact sacral nerve innervation.
   • In men, a prostate examination should be performed to assess for benign prostatic hyperplasia (BPH), which may contribute to urge or overflow UI.
4. Diagnostic Testing:
   • Diagnostic tests such as urinalysis, urine culture, and post-void residual (PVR) urine measurement can help identify UTIs or incomplete bladder emptying.
   • Advanced practice nurses or continence specialists can provide additional guidance based on these results.
5. Functional, Environmental, and Mental Status Assessments:
   • Observe the patient during voiding, assess mobility, and identify obstacles that may interfere with toileting.

Interventions and Care Strategies

Hospital nurses often lack the necessary knowledge for evidence-based incontinence care (Coffey et al., 2007; Connor & Kooker, 1996). Education and in-service training can help improve nursing care by identifying patients at risk for UI and implementing appropriate interventions. The North American Nursing Diagnosis Association (NANDA), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) provide frameworks for planning and evaluating UI management (Johnson et al., 2001).

1. Treating Transient and Functional Causes of UI:

• Identify and Treat Underlying Causes: Address medical conditions that contribute to transient UI, such as UTIs, constipation, or mobility limitations. Adjust medications that exacerbate incontinence.
• Promote Mobility and Toileting Assistance: Ensure access to toileting facilities, provide mobility aids, and consider scheduled toileting or prompted voiding programs.
• Environmental Modifications: Ensure that call bells are within easy reach and consider using elevated toilet seats, commodes, or urinals.
• Toileting Programs: Implement individualized, scheduled toileting programs (e.g., timed voiding) to help manage UI in patients unable to toilet independently. A voiding record is essential for developing these programs, and nurses should regularly assess and adjust the toileting schedule for optimal outcomes.

Nursing Interventions for Established UI

Nurses should focus on interventions tailored to the specific type of established UI:

1. Stress UI:

• Pelvic Floor Muscle Training (PFMT): Educate patients on pelvic floor muscle exercises, which strengthen the muscles that support the bladder and urethra, reducing stress UI episodes.
• Bladder Training: Encourage patients to gradually increase the time between voids to improve bladder capacity and control.
• Lifestyle Modifications: Counsel patients on weight management, fluid management, and avoiding bladder irritants like caffeine and alcohol.

2. Urge UI:

• Bladder Training and Scheduled Voiding: Implement bladder training and scheduled voiding programs to reduce urgency episodes and improve bladder control.
• Medications: Work with healthcare providers to explore antimuscarinic medications that can help relax the bladder muscle.

3. Overflow UI:

• Address Underlying Causes: Treat conditions like BPH or neurological disorders contributing to overflow UI.
• Catheterization: Intermittent catheterization may be required to relieve bladder distention and prevent urinary retention.

4. Functional UI:

• Environmental Modifications: Make modifications to the patient’s environment to ensure easy access to toileting facilities. Provide assistive devices and support as needed.
• Cognitive and Mobility Support: Encourage the use of memory aids, cues, and mobility assistance to facilitate toileting.

Treating Transient and Functional Causes of UI

First, transient causes of UI should be investigated, identified, and treated. Individuals with a history of established UI should have their usual voiding routines and continence strategies incorporated into the acute care plan. Nurses play a crucial role in discharge planning and patient or caregiver education regarding all aspects of UI.

Key Strategies:

1. Ensure Proper Environment:
   • Ensure call bells are within easy reach and consider the use of elevated toilet seats, commodes, or urinals.
   • Obtain referrals to physical and occupational therapy for assistance with activities of daily living and muscle strength improvement.
2. Avoid Restraints:
   • Avoid the use of physical and chemical restraints, including side rails, which may limit access to toileting facilities.
3. Implement Toileting Programs:
   • Toileting programs, such as individualized scheduled toileting or timed voiding, can help manage UI, particularly in patients unable to toilet independently. Continual assessment and adjustment of the toileting schedule are essential for success.
4. Education and Training:
   • Educate patients and caregivers about managing UI and provide support for behavioral interventions, such as PFMT and bladder training.

Introduction

Urinary incontinence (UI) is a prevalent issue among older adults, and its management has traditionally relied on containment strategies, such as using bedpans, urinals, commodes, urinary catheters, and various absorbent products (Harmer & Henderson, 1955; Henderson & Nite, 1978; Palese et al., 2007). However, beyond these containment methods, several other treatments are considered healthier bladder behavior skills (HBBS). These include dietary management, pelvic floor muscle exercises (PFMEs), urge inhibition, bladder training, toileting programs, pharmacological therapy, and surgical options (Fantl et al., 1996; Hodgkinson et al., 2008). This chapter focuses on HBBS, excluding pharmacological and surgical options, to promote better bladder control and quality of life for older adults.

The Need for Healthy Bladder Behavior Skills

Although HBBS are recommended for all older adults with UI (Fantl et al., 1996; Teunissen et al., 2004), there is a lack of clarity on effectively integrating these strategies into the care of hospitalized older adults. Nursing textbooks list HBBS as nursing interventions (Kozier et al., 2004; Newman & Wein, 2009; Taylor et al., 2005), but these interventions are not consistently implemented in acute care settings (Bayliss et al., 2003; Schnell et al., 2003; Watson et al., 2003). Barriers such as underreporting and inadequate assessment contribute to suboptimal management of UI in hospitals, with studies showing that only 0.1% of medical records captured UI as a problem at hospital admission (Schultz et al., 1997). Accurate assessment and identification of UI type are essential before initiating care strategies.

Assessing Motivation and Barriers

Before implementing HBBS, the nurse must assess the motivation of the patient, caregivers, and nursing staff, as behavior modification is a fundamental aspect of HBBS (Palmer, 2004). A patient’s willingness to participate in HBBS is critical to the success of these interventions. The nurse should discuss the benefits of HBBS with patients and caregivers, addressing any concerns or misconceptions they may have.

Dietary Management

Dietary modifications can play a vital role in managing UI. Nurses should educate patients to avoid foods and beverages known to irritate the bladder, such as caffeine, acidic foods, and NutraSweet (Gray & Haas, 2000). Patients with a body mass index (BMI) greater than 27 may benefit from weight loss programs. For instance, a study found that a weight loss of 5% to 10% significantly decreased UI episodes in some obese women (Subak et al., 2005).

Adequate fluid intake, especially water, is essential for maintaining bladder health. Nurses should work closely with patients, particularly those who fear that increased fluid intake will lead to more urine loss, to educate them on the adverse effects of inadequate hydration, such as volume depletion, dehydration, and concentrated urine that can increase bladder contractions and urgency. For patients experiencing nocturia, limiting fluid intake a few hours before bedtime may be advised (Doughty, 2000; Fantl et al., 1996). However, this advice may not be suitable for older adults without easy access to fluids or those with diminished thirst sensation (DuBeau et al., 2010). In the hospital setting, nurses should be mindful of diuretic schedules and consider adjusting dose times to reduce nocturia and the risk of falls, such as rescheduling diuretics from 10 pm to 6 am or 4 pm.

Pelvic Floor Muscle Exercises (PFMEs)

Pelvic Floor Muscle Exercises (PFMEs) are effective for treating stress and urge UI in community-dwelling, cognitively intact older adults (Hodgkinson et al., 2008). PFMEs strengthen the pelvic muscles, which are crucial for maintaining continence. However, the effectiveness of PFMEs as a primary prevention strategy for UI requires further research, particularly in acute care settings (Hay-Smith et al., 2002).

Integrating PFMEs into patient care involves assessing the patient’s baseline understanding of the exercises. Ideally, PFMEs are taught during a vaginal or rectal examination, where the clinician assists the patient in identifying the pelvic muscles by instructing them to squeeze around the gloved examination finger. This method allows for performance appraisal and, combined with regular follow-up, can improve UI outcomes for community-dwelling individuals (Tsai & Liu, 2009). Alternatively, PFMEs can be taught verbally by instructing the patient to contract the rectal or vaginal muscles without engaging the abdominal, buttock, or thigh muscles, which can increase intra-abdominal pressure.

Each PFME exercise should ideally consist of a 10-second contraction followed by a 10-second relaxation period. Some patients may need to start with shorter intervals, such as 3 to 5 seconds, and gradually increase as muscle strength improves. The recommended dose is typically 15 PFMEs three times per day. For community-dwelling women with stress, urge, or mixed UI, at least 24 PFMEs per day for a minimum of six weeks are advised (Choi et al., 2007; Syah, 2010). Although patients may notice improvement within two to four weeks, nurses should encourage compliance and refer patients to continence specialists for further follow-up and reinforcement, possibly using biofeedback (Bradway & Hernly, 1998).

Urge Inhibition

Urge inhibition is another behavioral strategy for managing urge UI, although the mechanism of how it works is not fully understood (Gray, 2005; Smith, 2000). This technique includes distraction methods, such as reciting a poem or song, relaxation techniques, and rapid pelvic floor muscle contractions to suppress the urge to void until a suitable time (Smith, 2000). By teaching patients these methods, they can learn to control their urinary urges better and prevent incontinence episodes.

Bladder Training

Bladder training is a behavioral technique used to treat urge UI and overactive bladder (OAB). It is often combined with urge inhibition techniques and Functional Incontinence Training (FIT) and may be more effective when paired with PFMEs or anticholinergic medications (Rathnayake, 2009a). Bladder training involves creating a baseline voiding record to establish the timing of voids and UI episodes. If urinary frequency is present, the patient is gradually trained to increase the interval between voids, retraining the bladder.

When a strong urge to void occurs, the patient is instructed to use urge inhibition techniques to suppress the urgency. For example, if the patient is not in a position to empty the bladder appropriately, the nurse teaches the patient to perform “quick flicks,” or quick, repetitive contractions of the pelvic floor muscles, to suppress the urge (Gray, 2005). Relaxation and distraction techniques are also beneficial during bladder training to manage the urgency.

Additional Techniques for Managing UI

In some cases, such as patients experiencing incomplete bladder emptying or overflow UI, Crede’s maneuvers (deep suprapubic palpation) can help facilitate bladder emptying. Crede’s maneuver involves manual compression over the suprapubic area during bladder emptying. However, this technique should be used cautiously and avoided if vesicoureteral reflux or overactive sphincter mechanisms are suspected, as it may dangerously elevate bladder pressure (Doughty, 2000).

Another technique, double voiding, may help patients achieve complete bladder emptying. This method involves instructing patients to attempt a second void after the initial void, which may help reduce urinary retention.

Incorporating HBBS in Acute Care Settings

Integrating HBBS into the care of hospitalized older adults requires overcoming several barriers, including inadequate knowledge and inconsistent implementation by nursing staff (Coffey et al., 2007; Connor & Kooker, 1996). Education and training programs, such as unit-based in-service sessions and patient rounds, can help identify patients at risk for UI and those already experiencing it.

Healthcare providers should use evidence-based protocols, such as those provided by the North American Nursing Diagnosis Association (NANDA), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC), to guide the assessment and management of UI (Johnson et al., 2001). Nurses should be proactive in identifying transient UI, advocating for appropriate interventions, and collaborating with interdisciplinary teams to optimize patient outcomes.