Elder Care In Hospital

Older Adults

Incontinence is not a normal part of aging; however, many factors can increase an older adult’s risk of incontinence, including:

  • Changes to body systems and organs
  • Having another illness(es)
  • Taking multiple medications
  • Experiencing problems with memory
  • Difficulty mobilizing and caring for self

Age-related changes to the urinary system can include:

  • Bladder muscle and message pathways not communicating as well
  • Not being able to hold as much urine
  • Increase in unnecessary bladder contractions
  • Weakened bladder contraction
  • Less physical awareness about bladder filling
  • Decreased kidney efficiency causing urine production at night
  • For women: the urethra closes less tightly, tissue thins and becomes dry as levels of estrogen drop
  • For men: the prostate gets bigger

These changes may results in a variety of symptoms, including:

  • Rushing to the bathroom because of delayed awareness of the bladder being full
  • Voiding more often because the bladder is not completely emptied
  • Getting up during the night to void
  • Women may leak urine, have more urgency, frequency and increased risk for urinary tract infections (UTIs)
  • Men may experience more difficulty passing urine, voiding in smaller amounts and dribbling

(Wagg et al. 2017, pp. 1316-1321)

Treatment Options

It is important to understand what may be adding to the risk of incontinence and reduce the impact of these factors as much as possible 

  • Assess medications that may be worsening incontinence
  • Review how to best mobilize patients and manage toileting for individual patients
  • Make sure clear signs show where the toilet is. This can include using pictures of a toilet, keeping bathroom doors open and using contrasting colours between the toilet and the floor

(Wagg et al., 2017; Palmer, 2016)

The pelvic floor functions to support the pelvic organs and oppose downward pressure.  These muscles may weaken or have a harder time supporting the urinary system with increased weight or a decrease in estrogen in menopause. Childbirth and surgeries (e.g. prostate) can also impact the function of pelvic floor muscles (Doughty, 2016).

Pelvic Floor Muscle Training (PFMT) is the most beneficial conservative option to address UI, in particular for stress urinary incontinence (SUI). PFMT should be offered if a physiotherapist with specialized training is available (Dumoulin et al., 2017). A physiotherapist can address incontinence that happens with day-to-day activities with functional training. Further explanation can be found in the video, It's Not TMI Episode 2: All About Kegels. Resources such Physiocanhelp.ca and consultation with a physiotherapist may help 

Obese women have higher intra-abdominal pressures, which increases the risk of urinary incontinence (UI) and potentially weakens pelvic floor supports. Lifestyle modifications that decrease body weight by 5% reduce the odds of developing UI at one year by 3% for every kilogram lost (Dumoulin et al., 2017). Resources such Canada’s Food Guide and consultation with a dietitian may help with weight reduction.

Other lifestyle modifications, such as smoking cessation, can reduce urinary symptoms. A study looking at overactive bladder symptoms (OAB) found that smoking increased the risk of more severe UI. When smoking was stopped, a decrease in urinary frequency was observed (Dumoulin et al., 2017).

Further information about the causes of urinary incontinence is available on the Canadian Continence Foundation website.

Resources

Anatomy

Diet

Exercise & Physiotherapy

There is a natural reduction in estrogen with ageing that contributes to an increase in overactive bladder symptoms and recurrent urinary tract infections.

Genitourinary Syndrome of Menopause (GSM) is a new term used to describe the vulvovaginal atrophy as well as the urinary symptoms of urgency, dysuria and recurrent urinary tract infections.  

Estrogen creams, tablets or rings used locally (i.e. vaginally) have been found to improve these symptoms, whereas systemic estrogen may actually worsen urinary incontinence (UI) (Andersson et al. 2017; Engberg, 2016).

Resources

The International Continence Society describes miscellaneous techniques for bladder control such as distraction techniques, urgency suppression and double voiding.

For many patients, not voiding with every urge will be a new concept. Healthy bladder emptying takes place every 3-4 hours. The goal is to increase bladder storage but avoid urinary retention (Yates, 2019). 

The ‘Knack’ is a functional pelvic floor technique where a patient is taught to contract the pelvic floor muscle (PFM) before coughing, sneezing or other activities that increase intraabdominal pressure to reduce the risk of stress urinary incontinence (SUI).

Frail older women with SUI may report that activities like getting up from a chair cause leakage, for example. Being taught to contract their pelvic floor muscles strongly (knack) before and during these activities may help (Engberg, 2016).

If the patient is unable to stand, the same exercises to locate the muscles can be done by turning legs and feet as described while lying down.

Intake of fluids impacts urine output, so getting an accurate idea of amount and types of fluids (e.g. water, alcohol, and caffeinated) is necessary (Palmer, 2016). Everyone's fluid intake requirement to stay hydrated is individual. Assessment of intake and output, timeframes, patterns of behaviour, incontinence, safety risk, and patients' preferences will impact fluid intake changes recommended.

Dietitians of Canada‘s UnlockFood.ca has several resources, including: 

General Recommendations

You’ll find useful advice on bladder leakage control from The Canadian Continence Foundation. Here are a few core recommendations: 

  • Avoid fluids that irritate the bladder (e.g. caffeinated beverages) or impact bladder control (e.g. alcohol). Caffeinated fluids cause kidneys to make more urine so decrease the amount and avoid drinking it in the evening. Some people may need to avoid citrus juices or fruits and tomato products; monitor symptoms. 
  • Drink 'healthy fluids': water, apple juice and grape juice. 
  • Intake a minimum of 5-6 cups of fluid each day (unless contraindicated).
  • Spread intake over the day to not overwhelm the bladder.
  • One to two cups of pure cranberry juice may help recurrent urinary bladder infections (UTIs). Stop or switch to oral capsules if urgency develops because it can be an irritating fluid.  
  • Stop fluids 2-3 hours before going to bed, empty bladder before going to sleep. 

(2020)

Caffeine

Caffeine may worsen urinary incontinence (UI) and increase overactive bladder (OAB) symptoms, urgency and frequency, though the association is not consistent.  

High caffeine intake (over 400 mg/day) is associated with OAB. Reducing below 100 mg/day decreases urgency and urgency incontinence. Switching to decaffeinated beverages lessens urgency and frequency. A trial and evaluation of reduced caffeine intake is recommended (Dumoulin et al. 2017; Gibson & Wagg, 2016).

Additional Resources

Diseases & Illness that Increase Risk of Incontinence

DISEASE OR ILLNESS INTERVENTION
Diabetes

High blood sugars cause more urine to be produced to try and get rid of extra glucose

Gain better control of diabetes
Joint Pain

Makes getting to the bathroom harder

Treat pain with medications and other things such as heat
Cough

Lung problems, such as COPD, can lead to coughing causing leakage (stress incontinence)

Try and reduce coughing with medications
Extra Body Fluid

Things such as leg swelling (edema) and heart-pumping problems (congestive heart failure) increase the amount of fluid the kidneys need to get rid of and cause people to void more often, especially at night

Controlling heart failure, reducing sodium, wearing support stockings, raising legs during the afternoon will help the body get rid of the fluids during the day
Constipation

If very bad, constipation can make it more difficult to pass urine

Treat constipation by eating lots of fruits and vegetables, increasing fiber and water, and taking medications to soften stool if needed
Stroke and Parkinson's

Affect a person's mobility causing a sense of urgency to try and make it to the bathroom in time

Regular help to go to the toilet is needed
Dementia

Have more difficulty with locating the toilet and being able to care for themselves properly after

Regular help is needed

 (Palmer, 2016 pp. 180-191; Wagg et al., 2017 pp. 1322-1323)

Lower Urinary Tract Symptoms (LUTS) Treatment Options

There are two types of overactive bladder: with incontinence (OAB wet) and without (OAB dry).

Overactive bladder is linked to comorbidity, lower quality of life, depression, and reduced work productivity. It increases with age and increases the risk of falls and fractures (Wagg et al., 2017; Diaz et al. 2017; Milsom et al., 2017). Urinary urgency is reported more often by people with benign prostatic hyperplasia (BPH), pelvic organ prolapse (POP) and mental health problems than those without (Milsom et al., 2017).

  • One time during the main sleep period is not considered meaningful; two times or more are, affecting quality of life
  • Count only voids followed by the hope to sleep
  • Do not include voids that happen just because you are awake

Important Facts

  • Associated with impaired mental and physical health, reduced quality of life and death
  • Increases the risk of falls and fractures
  • Risk factors include prostatic hyperplasia, urinary urgency/overactive bladder, obesity, sleep apnoea, having children
  • Risk doubles after menopause

(Milsom et al., 2017)

Treatment Options

  • Diet and exercise to improve diabetes control
  • Fluid restriction before bedtime, especially avoid caffeine and alcohol
  • Voiding before going to bed to empty bladder
  • Elevate edematous legs of older patients during the day and consider compression
  • Pelvic floor contractions to suppress nocturnal urgency 
  • Medical management of contributing factors such as sleep disorders, diabetes, cardiovascular disease and prostatic enlargement

 

Urgency can be experienced by people with or without overactive bladder.

Urgency can be a brain-to-bladder learned behaviour from certain stimuli, the most common:

  • On the way to the bathroom to urinate
  • Arrival at home/opening the door
  • First awakening
  • A full bladder

Behaviour treatments that delay or distract from the urgency can be helpful.

(O’Connell, Torstrick & Victor, 2014)

Urgency contributes to increased risk of falls in the case of those with poor mobility. For example:

  • Going frequently to the bathroom in an attempt to avoid incontinent episodes: a ‘just in case' pee
  • Factors such as overactive bladder (OAB), benign prostatic hyperplasia (BPH), or pelvic organ prolapse (POP)

(Chung, Katz & Love, 2017; Wagg et al., 2017)

It is important to assess contributing factors and, where possible, reduce risk.

Treatment Options

Urinary Incontinence Treatment Options

A 2014 study found that at least 4% of women and 2.12% of men in Nova Scotia have urinary incontinence (The Canadian Continence Foundation, 2014).

Many people do not discuss urinary incontinence (UI) with their health care provider because they think it is a normal part of aging, or they are embarrassed. It is important to assess not only the severity of symptoms (frequency, leakage amounts, etc.), but also the impact on activities, quality of life, and how much the patient is bothered by it (Milsom et al., 2017).

 

The Canadian Continence Foundation (2014) found that people with UI:

  • are more likely to be lonely
  • have a more difficult time with day-to-day activities
  • visit their physicians more often
  • spend more time in hospitals and nursing homes

UI that happens suddenly, lasts less than six months, and can usually be reversed is known as acute or transient incontinence. The common causes of Acute/Transient UI can be remembered using the mnemonic TOILETED.

UI that lasts longer than six months is chronic. The most common types of chronic UI are stress, urgency or a combination of both known as mixed UI. 

 

When both SUI and UUI are present (MUI), assess which is the most problematic for the patient and address those concerns first.

(Harris & Riggs, 2020)

Dubeau (2006) states that things outside of the urinary system can affect a person's ability to get to the bathroom in time to void; commonly known as functional incontinence.

Possible causes of functional incontinence:

(as cited in Palmer, 2016)

Changes to the brain may affect one's ability to recognize that the bladder is filling or what to do, as is the case with dementia. Problems with mobility can cause incontinence when one depends on others to get to the bathroom; it is delayed or takes too long to get there.

Treatment Options

  • Scheduled voiding regimens
  • OAB and urgency urinary incontinence treatment options
  • Improved access to the bathroom or utilize aids (e.g. commode, urinal, condom drainage)
  • Assistance mobilizing to toilet 
  • Safety equipment (e.g. grab rails, raised toilet seat, proper lighting)
  • Interdisciplinary collaboration and consultation
  • Absorbent products if appropriate 

Resources

Not all incontinence can be cured. Some patients may require a containment device or absorbent product on a temporary basis or long-term. Correct usage and skin care are essential (Wilde & Fader, 2016).

Key elements to assess are:

  • The nature of the continence problem
  • Gender-specific needs
  • Physical attributes (i.e. waist size, penile retraction)
  • Cognitive impairment
  • Mobility, leg abduction issues and dexterity
  • Eye sight
  • Lifestyle/environment
  • Independence/assistance
  • Access to laundry facilities
  • Personal preferences and priorities

(Cottenden et al. 2016)

Consultation with an occupational therapist or nurse specializing in continence care (i.e. NSWOC, NCA) may be helpful, especially for less familiar products such as sheaths, body worn urinals, internal urethral devices (women), penile compression devices, fecal pads, fecal collectors and anal devices.

Continence Products and Catheter Resources

Incontinence Associated Dermatitis (IAD) is a risk for frail elderly skin who are incontinent of urine or feces. Gentle cleansing with a pH-balanced no-rinse cleanser, hydration of dry skin, protection with a barrier product, and ongoing monitoring to prevent further injury such as a pressure injury is recommended (Beele et al., 2018).

Resources for IAD

Bladder Diaries

Bladder Diaries provide comprehensive, objective information when assessing for urinary incontinence, and support the evaluation of treatments. 

Important information includes:

  • Times voided
  • Fluid intake (including food with water content, e.g. soup)
  • Volume of fluid output
  • Incontinence episodes
  • Frequency of changing pads or clothing
  • Urgency assessments
  • Degree of leakage (slight, moderate or large)
  • Descriptive causes of symptoms (e.g. coughing)

ICS Standards (2019) recommend a bladder diary should be kept over a three day period and include any days that are routine variations (i.e. work/weekdays versus weekend).

When patients find it challenging to collect for three days, a 24-hour collection can also be useful.

A bladder diary can also be helpful as a way for the patient to see changes with treatment. For example, timing of fluid intake and reduction in nocturia (Diaz et al., 2017).

Scheduled Voiding

Bladder training can be helpful to improve Increased Urinary FrequencyNocturiaUrgencyUrinary Incontinence, and Overactive bladder (OAB, urgency) Syndrome.

  • Correct habits/patterns of frequent urination
  • Improve control over symptoms of urgency
  • Increase time between needing to void
  • Increase amount bladder can hold
  • Reduce incontinence accidents
  • The patient becomes confident in being able to control bladder function

Typical Regimen

  • Start at one-hour intervals while awake
  • Increase by 15-30 minutes per week depending on the patient's tolerance. If voiding time less than an hour initially, then adjust timeframe accordingly.
  • Inpatient bladder training programs might advance at a faster rate (i.e. daily time increase) if improvement noted
  • Depending on patients, feelings of control over urgency and confidence, increase the time until a two to three hour interval is reached
  • Patient education about ways to control urgency (e.g. distraction, relaxation and pelvic floor contractions)
  • Use bladder diary for patient to self-monitor and evaluate progress
  • The health care provider should provide positive reinforcement of progress

(Dumoulin et al., 2017; International Continence Society, 2020)

Timed voiding is a fixed voiding schedule that doesn’t change over time.

  • Prevent urinary incontinence by offering regular chances to pee before the bladder is too full
  • Use with patients who cannot participate in independent toileting (i.e. due to cognition, mobility)
  • Women with mild UI, infrequent voiding patterns with normal bladder function may benefit 
  • A timed voiding of every two hours is the usual recommendation while awake
  • Additional supports such as pads, condom drainage may be used at night

(Dumoulin et al., 2017; International Continence Society, 2020)

Habit training is a toileting schedule that is based on the patient's voiding pattern.

  • Mainly used by caregivers of people with cognitive and/or physical impairment
  • May be helpful for others without impairment who have a regular pattern of urinary incontinence
  • Determine voiding pattern using a bladder diary
  • Toileting scheduled according to a time shorter than usual pattern before an incontinent episode. For example, a patient who voids every 4 to 5 hours and is incontinent every 4.5 hours would toilet every 4 hours.

A bladder diary could be done to evaluate if there was any improvement in the number of UI episodes.

(Dumoulin et al., 2017; International Continence Society, 2020)

Prompted voiding is a voiding program that works towards increasing the number of initiated requests to go to the bathroom.

  • Caregiver education program in combination with a scheduled voiding regimen
  • Usually every two hours
  • Used with people with and without cognitive impairment to initiate their own toileting requests for help
  • Uses positive reinforcement from caregivers

(Dumoulin et al., 2017; Registered Nurses' Association of Ontario, 2020)

Medication Review

It is important to review medications to assess if they are contributing to the signs and symptoms reported by the patient (e.g. frequency, urgency, incontinence). This review should include all prescription and over-the-counter medications.

Pharmacists are a very valuable resource when evaluating medications for potential risks. Medication review is particularly important for elderly patients. The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults (2019) is a great tool.

Many types of medications can cause or contribute to the development of urinary incontinence in older patients, such as:

MEDICATION POSSIBLE SIDE EFFECTS
Alpha-adrenergic agonists (e.g. Methyldopa, Guanabenz) Increased urethral tone may cause urinary retention
Alpha-adrenergic antagonists (alpha-blockers) (e.g. Doxazosin, Prazosin) Reduces urethral tone increasing the risk of stress incontinence
Angiotensin-converting enzyme (ACE) inhibitors (e.g. Enalapril, Ramipril) Chronic cough is a common side effect, increases the risk for stress incontinence
Anticholinergics (e.g. Dimenhydrinate, Amitriptyline, Oxybutynin) May affect bladder emptying, the potential for urinary retention, constipation and dry mouth. Risk of confusion can lead to a decline in awareness of the need and ability to toilet.
Calcium channel blockers (e.g. Diltiazem, Verapamil) May affect bladder emptying, potential urinary retention, and constipation. Increased nocturia due to contributing to leg edema.
Cholinesterase inhibitors (e.g. Donepezil, Galantamine, Rivastigmine) Increase bladder contracts which may increase urgency and/or emptying incontinence
Diuretics (e.g. Furosemide) Increase urine output, frequency, and urgency, and risk urgency incontinence
Opioid analgesics May cause delirium, urinary retention and constipation
Sedatives and Hypnotics May cause drowsiness, cognitive impairment which can affect recognition of the need to void, ability to mobilize and toilet
Decongestants (e.g. pseudoephedrine-Sudafed) Increase urethral tone and risk for retention in men with prostate enlargement

(Finck et al., 2019; Nelles, 2016; Wagg et al., 2017)

2019 American Geriatrics Society Beers Criteria® Update Expert Panel, Fick, D. M., Semla, T. P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C.E., Pezzullo, L., Epplin, J.J., & Flanagan, N. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4),674-694.
https://www.libraryproxy.nshealth.ca/login?url=https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.15767

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