Continence. Who cares and does it matter? Dr Carl Hanger Geriatrician, CDHB SI Alliance Stroke Education Day 2/11/17

Transcription

1 Continence. Who cares and does it matter? Dr Carl Hanger Geriatrician, CDHB SI Alliance Stroke Education Day 2/11/17

2 1500 pages, leading stroke experts

3 Does it Matter? Definitely! Patient Dignity / QOL Independence Sleep disturbance Social life Mood

4 MC Brady et al; Clin Rehabil 2016: 30,

5 Prevalence and Mortality Outcomes 32-79% of all strokes have UI on admission UI poor prognosis Reflects more severe strokes/comorbidity Reduced awareness of UI worse Improved continence may improve outcomes (Barer D 1989)

6 But do we (health professionals) care? It seems not! Australian National Stroke Audit % of acute stroke patients had incontinence Yet only 1/3 had incontinence management plan

7 Post stroke voiding dysfunction Not always urinary incontinence May have urgency, frequency and nocturia (OAB, detrusor hyerreflexia) Terms of neurogenic bladder, neuropathic bladder, neurologic bladder dysfunction are unhelpful and non specific detrusor hyperreflexia, detrusor hyporeflexia, (detrusor-sphincter dyssynergia) Comorbid conditions Pre-existing UI, BPH, diuretics, bladder antispasmodics

8 Int J Clin Pract 2013:67:

9 PMC Int J Clin Pract 2013:67:

10 PMC Int J Clin Pract 2013:67:

11 PMC Int J Clin Pract 2013:67:

12 Suprapontine stroke loss of tonic inhibition of PMC giving Detrusor overactivity, [but also loss of sensation, reduced awareness of timing, mobility or cognition] PMC Int J Clin Pract 2013:67:

13 loss of coordination of micturition via PMC giving detrusor overactivity, detrusor-sphincter dys-synergia, or detrusor underactivity (retention) Pontine stroke PMC Int J Clin Pract 2013:67:

14 New Clinical Guidelines for Stroke Management 2017 The 2017 Australian Clinical Guidelines for Stroke Management are now available and largely replace the 2010 New Zealand Stroke Guidelines. These Guidelines were developed with input from New Zealand stroke clinicians including several members of the New Zealand National Stroke Network. The Guidelines focus on scientific evidence to support best practice care and most of what is included in the Australian Guidelines is fully applicable to stroke care in New Zealand.

15 Stroke-Management-2017

16 Structured continence assessment Portable Bladder scanner Structured management plan Community plan May need specialist review Anticholinergic drugs Prompted or scheduled voiding programme Containment

17 Try to avoid IDCs If retention consider Intermittent catheterisation If discharged with IDC, teach patient/family Whole team approach for functional incontinence Avoid IDCs except acute urinary retention

18 Types of Urinary Incontinence Mehdi Z et al, Int J Clin Pract 2013;67:

19 Normal Voiding Physiology (Panel A) Involuntary Detrusor Contraction Commonly Associated with Symptoms of Overactive Bladder (Panel B) Ouslander J. N Engl J Med 2004;350:

20 Case 1 9/7/17 Mr U, 67 truck driver P/w aphasia, R hemiplegia, confused, R inattention Given tpa Complicated by pulm emboli, OSA Rehab Alert, language improved BP 105/60 PVR 45mls Urge urinary incontinence

21 Case 1 : Urge incontinence Some reduced awareness of need to PU (improving) Worsened by immobility (currently 1p assist, quad stick, laboured gait) Nocturnal incontinence (helped with bottle and improved transfers to side of bed) Avoid pads at night, as made urgency more difficult to manage Got despondent when UI regressed with UTI. Mood improved as UI resolved again

22 Case 2 Mr L, 81. Lives in retirement village unit. P/w L weakness, drowsy, drooling and dysarthria. Acute urinary retention (was on oxybutynin), followed by successful TOV Faecal incontinence resolved with change laxatives Urinary incontinence- reduced awareness. Complained of poor sleep, urinary frequency

23 Case 2 : Overflow Incontinence Bladder (dam) already full to capacity Any extra flow in, spills over spillway (dribbling incontinence, with no control)

24 Brain Bladder Mobility

25 Functional Incontinence Mobility Language Apraxia Decreased sensation / awareness / interpretation Impaired cognition Delirium Drowsy

26 DIAPPERS Delirium Infection (UTI) Atrophic vaginitis Pharmaceuticals Psychological Excess fluids Restricted mobility Stool (constipation)

27 Drugs causing incontinence Alcohol diuretics anticholinergics cholinesterase inhibitors alpha agonists and antagonists ACE inhibitors (cough) Ca channel blockers opioids/sedatives/hypnotics

28 MANAGEMENT OF URINARY INCONTINENCE IN OLDER PEOPLE

29 Voiding Diary

30 Catheters after Stroke Catheter use associated with increased age and stroke severity Independently assoc with poor outcomes (such as mortality) Do IDUC make things worse? G John et al, J Stroke and Cerebrovasc Dis 2017 (in press)

31 Catheters after Stroke Most were for retention Probable detrusor hyporeflexia No association seen with gender or use of anticholinergic medications Complication rate is high (38%) BUT > 90% can have their IDC removed At least half will regain continence Smith N, Hanger HC 2013

32 Intermittent self catheterisation? Guidelines recommend Issues with one handed techniques Extrapolation from non stroke literature

33 What can we do? Acknowledge incontinence Diagnose type and severity incontinence Post void residual volume scan Voiding diary Urodynamics (selected patients)

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35 Not just pads!

36 More than just pads Timed or prompted voiding more effective than anticholinergics

37 GOOB??

38 Can we do drugs? Stop some Start some (may be)

39 Whole Team vs Nursing Role? Are you setting rehabilitation goals for continence? Containment vs rehabilitating back to continence?

40 Focus on regaining continence Small study 13 standard rehabilitation ward (control) 21 rehabilitation ward using repeated FIM scores (intervention) Twenty patients(20/21) in the intervention group regained continence before discharge compared to 3 (p < 0.01) in the control group. Wikander B et al. Scand J Rehab med 1998:30:15-21

41 Going home with incontinence Have you achieved goals for continence? Has carer/ patient been taught skills? Eg urodome Have we provided the right equipment? Don t under estimate the effects of nocturnal incontinence on the carer

42 Take Home Points Portable US bladder scanner What does a personalised continence plan mean? Specific to that individual Write down all his/her barriers to continence and toileting How are some or all of these to be tackled? Write down the plan for others to follow! Communicate!

43 Resources Stroke Training and Awareness Resources (STAR) Evidence Based Review of Stroke Rehabilitation (EBRSR) Stroke Guidelines 2017 (Australian [and NZ]) Management-2017

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45 Travel urinals

46 Environment

47 Clothing