Running head: INCONTINENCE IN THE OLDER ADULT

Factors, Types and Nursing Implications of Incontinence in the Older Adult Dermot Connolly Stenberg College

INCONTINENCE IN THE OLDER ADULT Abstract

Incontinence can play a significant role in the lives of the older adult. The loss of self confidence and embarrassment that is often associated with the condition can have a serious impact on the individuals quality of life. This paper examines the many factors that lead to incontinence and the different types of incontinence commonly experienced in the older adult population. The importance of the nursing role in identifying, assessing and treating incontinence is also emphasized. Keywords: Incontinence, Quality of life, types, contributing factors, nursing implications.

INCONTINENCE IN THE OLDER ADULT Factors, Types and Nursing Implications of Incontinence in the Older Adult Urinary and fecal incontinence (UI and FI) is a common problem associated with the older adult affecting over 50% of the residents in nursing homes Leung & Schnelle (2008). The impact on the lives of those who suffer from incontinence is significant, as it limits their ability

to carry out many daily activities. UI an FIs can also be a source of embarrassment for the older adult resulting in increased seclusion from society, which in turn can lead to a decrease in the quality of life and depression. Cotterill, (2011). In terms of defining a UI and FI, there is broad agreement, where urinary continence is defined as the involuntary loss of urine sufficient to be a problem Touhy, et al (2012) p140. Cotterill, has a similar definition, which he defines as the complaint of any involuntary loss of urine. Cotterill (2011) p51. He goes on to define fecal incontinence as any involuntary loss of fecal material. Cotterill (2011) p52. There are many factors which can contribute to a UI or FI. Some of the more common causes in the older adult include immobility and dementia. Leung & Schnelle (2008), and age related changes of the bladder. Touhy, et al (2012). Similar factors are responsible for FIs but other factors such as blindness; arthritis and stroke also play a part. Leung & Schnelle (2008). The different types of incontinence are dependant on the cause. Stress urinary incontinence for example is caused by a weakness in the pelvic floor muscles or defective urethral sphincter, NAFC (2012), whereas fecal incontinence is commonly associated with a problem with the nervous system. Hillary (2009). With such a variety of factors and types of incontinence, the ability to treat and care for the individual is therefore very important. This treatment begins with an assessment on the persons quality of life and how a UI or FI can negative impact it. Cotterill, (2011). Other important incontinent assessment tools include keeping up to date with new treatment options, Thomas (2008) and being more aggressive in its control and management. Touhy, et al (2012).

INCONTINENCE IN THE OLDER ADULT With incontinence playing such an important role in the lives of the older adult, the types of incontinence, contributing factors and nursing implications are important considerations for the psychiatric nurse. Many factors contribute to UI and FIs. Limitations on the mobility of the older adult

contribute to the large proportion of incontinence cases reported in residential care homes. Leung & Schnelle (2008) reported that 60% to 90% of incontinence sufferers in residential care homes had restricted mobility. They also reported that the average Mini Mental Status score of a resident suffering from incontinence ranged from 8-14 out of 30, indicating that incontinence is directly linked to a deterioration in cogitative ability Leung & Schnelle (2008) Para 7. Nordqvist (2012), who also associates neurological diseases such as Multiple Sclerosis and Alzheimers with FIs, reiterates theses factors. Gender also plays a factor in FIs with women being more susceptible than men due to possible complications of childbirth. Nordqvist (2012). Similar conclusions were also drawn by Touhy, et al (2012), although they make the important point that cognitive impairment does not cause incontinence, it merely prevents the resident from recognizing when it is time for them to go to the bathroom. Touhy, et al (2012). They also recognize other contributing factors to incontinence such as strokes, diabetes, obesity and poor general health Touhy, et al (2012) p141. As mentioned above, immobility and dementia are key factors associated with FIs in the older adult. Some studies show that up to 46% of residents in long-term care homes suffer from some form of FIs. Leung & Schnelle (2008). These incontinence factors can however be controlled or minimized through the implementation of voiding programs where residents are taken to the bathroom at scheduled intervals during the day. In one study where this approach was employed, the amount of appropriate bowel

INCONTINENCE IN THE OLDER ADULT movements made by incontinent residents in care home increased from 23% to 60%. Leung & Schnelle (2008). Just as there are several factors that contribute to incontinence, there are also several

types of incontinence. Attempting to identify the different types of FI is quiet straight forward as the term is used to describe the inability to control all bowel movements including gaseous, liquid and sold stool. FI varies only in their ability to control either a partial or full movement of the bowel. NAFC (2012). UIs on the other hand are more complicated with several different types being identified. Stress incontinence in caused by an inefficient pelvic or sphincter muscle. When these muscles are placed under stress such as laughing or sneezing, additional pressure is placed on the bladder resulting in urinary stress incontinence. Hillary, (2009). Another common type of UI is called an urge incontinence which is characterized by an overactive bladder. Touhy, et al (2012). Urge incontinence is characterized as the involuntary loss of urine that occurs soon after feeling an urgent need to void Touhy, et al (2012) p142. Urge incontinence is common among residents suffering from a stroke or other neurological disease such as Alzheimers, Parkinsons or Multiple Sclerosis. Hillary, (2009). Diabetes is a common cause for another type of UI called overflow incontinence. Overflow incontinence is characterized by a bladder that overflows as a result of incorrect signals being sent to the brain telling it how full the bladder is. Hillary, (2009). Other causes of overflow incontinence include a blocked urethra as a result of fecal impaction or an enlarged prostate. Touhy, et al (2012). Surgery is also a contributing factor in UIs, where the pelvic muscles are damaged resulting in leakage due to it function being compromised. Surgery incontinence can affect both men and women who undergo invasive procedures such as tumor removal, hysterectomies, prostate procedures and caesarean sections.

INCONTINENCE IN THE OLDER ADULT Hillary, (2009). While the factors and types of incontinence are varied, their monitoring and control can result in an improved quality of life for the sufferer. While incontinence can be improved quiet easily once the appropriate care has being provided, It is an unfortunate reality for the older adult that many of the treatment options

available are dependant on the quality of nursing care provided. Mangnall (2008). Many nursing staff are of the understanding that incontinence in the older adult is a normal part of aging and devote much of their efforts in containing the problem instead of curing it. Mangnall (2008). As psychiatric nurses, this is an important point as we have a responsibility to provide the highest quality of nursing care to our patients in accordance to our code of ethics which states that we practice within ones own level of competence and seeks out additional information or guidance when required. RPNC (2010) p4. We have a responsibility therefore to ensure we educate ourselves on all advancements in the treatment and control of incontinence. The National Institute for Health and Clinical Excellence (NICE) for example has established guidelines to ensure all health care workers are exposed to the necessary assessment and treatment options available for patients suffering from incontinence. Mangnall (2008). The guideline also provides information to the patients about their disorder and includes suggestions for appropriate questions to ask. Mangnall (2008). Developing an empathic relationship with the resident can also go a long way in ensuring proper and adequate nursing interventions are taken to treat incontinence. One way in which this empathic relationship can be developed is through the evaluation on the patients quality of life and the impact incontinence has on that quality. Cotterill, (2011). Such evaluations are best carried out using questionnaires which allow for assessments to be standardized and compared with a larger population of incontinence sufferers. It also allows the patient to reflect on the impact incontinence has played on the quality of their

INCONTINENCE IN THE OLDER ADULT lives. Cotterill, (2011). In addition to written assessment tools, other nursing interventions are available for the psychiatric nurse when dealing with a patient with incontinence. These interventions concentrate on the promotion of healthy bladder control and muscle exercises. Touhy, et al (2012). Some of these interventions include the introduction of scheduled voiding which promotes regular toilet breaks ever two to four hours. Other strategies include bladder training where the interval between toilet breaks is gradually increased. Touhy, et al (2012).

Other interventions involve strengthening the pelvic muscles where the pubococcygeal muscle is strengthened through repetitive contractions Touhy, et al (2012). Weight loss and surgery are other examples of treatment options available for the intervention of incontinence. Although used only in extreme cases, surgery helps provide additional support to the bladder or rectum, whereas muscle spasms can be controlled through the use of Botox injections. Jenkins (2012).

Incontinence can have a significant impact on the quality of life of the older adult. Cotterill, (2011). It can negatively impact the individuals ability to carry out their activities for daily living (ADLs), which in turn can affect their mobility, self-confidence and social interaction. With many different factors contributing to incontinence and many different types being diagnosed, its successful management and care is an important aspect in the role of a psychiatric nurse. It is an unfortunate fact that many nurses are of the opinion that incontinence is a normal part of the ageing process Mangnall (2008), and is often left untreated as a result. Many treatment options are available including bladder care; muscle strengthening Touhy, et al (2012) and surgery Jenkins (2012). However without a complete understanding of incontinence, it will be impossible to create a treatment strategy that meets with the needs of the individual suffering from the condition.

INCONTINENCE IN THE OLDER ADULT References

Cotterill, N. (2011). Quality of life issues in continence care. Nursing Standard. (26) 8. 51-56.

Hillary, B., (2009). Incontinence types and information. Retrieved from: http://www.disabledworld.com/health/aging/incontinence.php

Jenkins, G. (2012). Incontinence. Retrieved from: http://www.bbc.co.uk/health/physical_health/conditions/incontinence.shtml

Leung, F., W. & Schnelle J., F. (2008) Urinary and fecal incontinence in nursing home residents. US National Library of Medicine National Institute of Health. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2614622/

Mangnall J., (2008). A guide to the management of incontinence in older people. Gastrointestinal Nursing. (6) 5. 36-39.

National Association for Incontinence. NAFC (2012). The basic types of urinary incontinence. Retrieved from: http://www.nafc.org/bladder-bowel-health/types-of-incontinence/

Nordqvist, C., (2012). What is bowel continence? What is fecal incontinence? What causes bowel incontinence? Medical News Today. Retrieved from: http://www.medicalnewstoday.com/articles/165583.php

Thomas, S., (2008). Consider continence essential to quality of life. British Journal of Neuroscience Nursing. (4) 11. 554-555.

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Touhy, T., Jett, K, Bocart, V. & McCleary, L. (2012). Ebersole and Hess Gerontologial Nursing & Healthy Aging. Elsevier: Canada.

Registered Psychiatric Nurses of Canada. RPNC (2010). Code of Ethics. Retrieved from: http://www.crpnbc.ca/wp-content/uploads/2011/02/2010_Code_Standards.pdf