The Management of Urinary Incontinence in Residential and Nursing Homes for Older People

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1 Age and Ageing 1996:25: The Management of Urinary Incontinence in Residential and Nursing Homes for Older People S. M. PEET, C. M. CASTLEDEN, C. W. McGROTHER, H. M. DUFFIN Summary We assessed the management of urinary incontinence amongst older people in residential and nursing homes and examined strategies for continence care in the homes. A random sample of local authority and private residential and nursing homes was drawn from an earlier census of long-term care. Strategies for continence care, the standard of care provided and the need for more help were determined by means of a structured questionnaire and the observations of a continence adviser. A random selection of residents in each of the homes was assessed for the presence, severity and symptoms of urinary incontinence, for symptom control and physical dependency. Eighty-seven per cent of the homes used pads and 83% daytime toileting to promote continence care but only 52% practised night-time toileting and 49% the use of clear toilet signs. A greater emphasis was placed on incontinence management rather than continence promotion, the latter being 'good' in only 32% of homes. Although the majority of homes reported having adequate access to aids and appliances, 39% of residents had severe symptoms of urinary incontinence resulting in bed-wetting and wetting of clothing. Substantial social and psychological effects were found; 87% of residents needed changes in their management of the condition and incontinence management was 'good' in only 47% of homes. Although 73% of homes were optimistic about offering good continence care, they were infrequently supported by continence nurses (30% of homes) or specialist continence doctors (9% of homes). Consequently 57% requested more help from the specialist services. The high prevalence of severe and uncontrolled symptoms of urinary incontinence combined with the lack of support received by the homes for the management of these residents indicated the urgent need for a greater input from the specialist continence service. Introduction Urinary and faecal incontinence are known to affect a substantial proportion of older people in residential care [1 3]. A census of Leicestershire homes and hospitals found that over two-fifths of older people in long-term care were regularly incontinent of urine [4]. This condition adversely affects quality of life [5-7] and causes distress [7, 8] despite the effectiveness of interventions to cure or alleviate symptoms [9, 10]. Moreover, the control or alleviation of symptoms is sometimes impeded by the belief that incontinence is to be expected in old age and is not amenable to treatment. Previous studies have demonstrated, for example, that general practitioners (GPs) may refer less than 5% of older incontinent patients to specialist continence services [7] and that around 40% of GPs never use these services for older people [11]. In order to optimize the care provided for incontinent older people in long-term care it is necessary to ensure that the level of available expertise and experience in the care of incontinent residents is appropriate. Carrick and colleagues, for example, who assessed psychiatric inpatients (of all ages), reported that inadequate strategies for the management of incontinence resulted in the poor control of symptoms [12]. Not only is this very distressing to the sufferer, but it also contributes to the workload of the home which cares for them [13]. The aims of the present study were: to assess the nature of incontinence among older people in residential care; to examine individual management techniques and identify if changes were needed; to assess the strategies which residential and nursing homes had developed to care for incontinent residents; and to highlight areas in which the homes needed more support. Methods In November 1990 a census of all people aged 65 years and over in long-term care was carried out in Leicestershire [14].

2 140 S. M. PEET ET AL. This included questions relating to urinary incontinence, faecal incontinence and the use of continence aids and has been described previously [4], Following the census, a random sample was drawn of 20 local authority, 20 private nursing and 40 private residential homes who had reported having incontinent residents. More private residential homes were sampled in order to reflect the greater number of small homes of this type. Questionnaires were then completed on a selection of residents and relating to the homes themselves, as follows: The residents; An updated resident list was compiled from which two incontinent residents were randomly selected from each local authority and private nursing home and one resident from each private residential home, with the intention of assessing 40 cases from each sector. Catheterized patients were excluded as many of the questions would not have applied to such patients. Assessments were conducted for 37 incontinent residents in 19 local authority homes, 36 residents from 36 private residential homes and 23 residents in 13 private nursing homes. Fewer assessments were completed in nursing homes because a higher rate of refusals from proprietors in this sector resulted in only 13 homes being recruited to the study of which only 11 reportedly had any incontinent residents. A structured questionnaire schedule gathered data on: (i) The presence of urinary incontinence, as distinguished by the questions: 'Do you have any difficulty controlling your water/urine?' and 'Do you ever lose control, even for a short time, so that any urine escapes?'. (it) Severity, defined as: Mild damp or wet underclothing or an equivalent use of pads; Moderate wet outer-clothing or up to five midi-pads per day; Severe saturated clothing or furniture, equivalent to one or more high-absorbency pads per day. (Hi) Symptoms and symptom control including: nocturia and urgency, use of aids and appliances, control of external wetting, continence promotion, drug therapy, the social and psychological effects of incontinence and the wish to receive help. (iv) Physical dependency: based on functioning in activities of daily living as described previously [4]. The Homes: Each of the homes was assessed for: (a) Strategies for incontinence: policies for admission, incontinence management and continence promotion, (b) Need for more help by the homes: staffing levels/training, support from health services, access to continence aids and the perceived need for help, (c) Standard of continence care: staff assessment, continence adviser's assessment based upon regime type, staff sensitivity towards incontinence, incontinence management and continence promotion. Table I. Policies for managing incontinence and promoting continence in residential and nursing homes for older people in Leicestershire Policies for incontinence management and continence promotion Incontinence management Use of continence pads Use of continence sheets Personalized bathing policy* Use of appliances and catheterization Continence promotion Daytime toileting Use of aids to promote continence Night-time toileting Toilet signs Fluid restriction Admission policyf of homes with stated policy 87 (62) 62(44) 51 (33) 41 (29) 83 (59) 68 (48) 52 (37) 49 (35) 38 (27) 21 (15) 16% had no bathing policy; 32% had a rigid once or twice weekly policy. f Patients specifically precluded from admission by existing incontinence. areas, particularly of continence promotion, were relatively neglected (Table I). The residents: Incontinent residents (herein referred to as 'cases') were very elderly (mean age of 84.3 years) and predominantly female (81%). Many were dependent in aspects of daily living such as washing/dressing (68% needed help) and mobility (85% were not fully ambulant), reflecting an expected higher level of disability among incontinent cases. Forty-three per cent of cases were categorized as having high physical dependency, which was significantly lower than the prevalence amongst incontinent residents identified by the original census [4] (x 2 = 23.76, df = 1, p < 0.001). Sixty-nine per cent of cases were incontinent of urine most days and 39% experienced severe symptoms, to the extent that many regularly had wet outer-clothing or wet the bed (Table II). Control of external wetting Table II. Degree of external wetting amongst incontinent older people in residential and nursing homes in Leicestershire Degree of external wetting of cases* Results Strategies for continence care: Little strategic control of levels of incontinence in the homes was being attempted at admission, with only 21% of the homes reporting a policy relating to the intake of incontinent residents. Most of the homes reported having policies relating to incontinence management and some aspects of continence promotion, although other Wet underclothing Wetting the bed Wet outer-clothing Wetting of furniture Causing pools of urine 54 (52) 40(38) 34(33) 21 (20) of cases regularly experiencing this degree of external wetting. These are not mutually exclusive categories.

3 MANAGEMENT OF URINARY INCONTINENCE 141 Table III. Access to continence aids and appliances amongst residential and nursing homes for older people in Leicestershire Table V. Need for individual changes in the management of urinary incontinence amongst older people in residential and nursing homes in Leicestershire Sufficient access* to aids and appliances Incontinence pads Continence sheets Appliances Other aids of homesj" 86 (61) 75(15) 69 (49) 72(51) 'Sufficient access' was self-defined by the Officer-in-Charge or other staff member interviewed. f These are not mutually exclusive categories. was complete for only 27% of cases. The main symptoms experienced in the cases were difficulties with micturition (72% of males), frequency (64%), urgency (55%) and nocturia (40%). Onset had occurred within the previous year for 27% and after admission in 30% of cases. As indicated by the homes' policies (Table I), incontinence management proved to be the prime aspect of the homes' continence strategy (with 87% of cases using aids and/or appliances). The majority of homes reported having sufficient access to continence aids (Table III) although 58% of the private sector homes had been adversely affected by the withdrawal of free aids by the Health Authority. At least 21% of private homes thought that this had adversely affected the quality of continence care, 33% that it had affected the cost of a place, 25% reported that residents' spending money had been affected and 46% stated that it had increased the financial burden on the residents' families. The majority of cases (88%) were taking one or more prescribed drugs but only 2% were taking drugs to manage incontinence, these being oxybutynin and terodiline. However, 40% of cases were taking diuretics, of whom two-thirds were using the powerful loop diuretics, frusemide and bumetanide. Continence promotion was being used less widely and not at all in the case of pelvic-floor exercise (Table IV). The social and psychological effects on residents were substantial with 26% of cases reporting social Table IV. The use of continence promotion amongst incontinent residents of residential and nursing homes for older people Continence promotion technique of cases Aspect of management requiring change Incontinence management No./type of incontinence pads Drug therapy Use of appliances Continence promotion Investigation Bladder training Toileting Use of continence aids Fluids of cases 25 (24) 15(14) 47 (45) 31 (30) 27 (26) 12(11) problems caused by their incontinence and 55% admitting to feeling upset or depressed. Despite this, however, only 13% had sought professional help within the previous year, of whom 12% had consulted their general practitioner, 5% a district nurse and only 1% a continence specialist. Consequently, 40% stated that they wanted further help for the problem. This was confirmed by the continence advisers' finding that 87% required changes in the management of their incontinence, especially in terms of diagnostic investigation (Table V). Standard of continence care: Training in the care of incontinent residents had been provided for a little over one-half of care staff (56%). Despite this, the homes were generally optimistic about offering a good standard of continence care within existing staffing levels (73% felt this was possible) and morale was reported to be 'high' in 78% of homes. In contrast, the continence advisers found that incontinence management was 'good' in less than half the homes (47%) and continence promotion was 'good' in only one-third (32%), despite a high degree of staff sensitivity in twothirds of the homes (66%). Need for more help by the homes: The homes sought advice for the care of incontinent residents most frequently from the district nurse (54%), followed by general practitioners (32%), and specialist continence nurses (30%). Only 9% of the homes had received support from a specialist continence doctor (although 24% were unsure about this). Consequently two-fifths (39%) of the homes felt that they needed 'a little' additional guidance and a further 28% reported needing 'a lot' of further help. One or more techniques Toileting Fluid adjustment Bladder training Pelvic-floor exercises 57 (55) 46(44) 16(15) 6(6) 0(0) Discussion The prevalence of urinary and faecal incontinence is exceptionally high in older patients in all types of NHS hospitals and in residential and nursing homes [4]. This survey concerned only residential and nursing home

4 142 S. M. PEET ET AL. care, but revealed that 39% of cases experienced severe symptoms of urinary incontinence, 22% had poor symptom control and 87% required changes in their management. This, combined with the infrequent use of continence promotion and the widespread request for more help, indicated a considerable potential for the input of a specialist continence service. Difficulties in micturition amongst men suggested the potential to identify and treat prostatic problems and another important finding was that diuretics were used by two-fifths of cases, of whom two-thirds were taking loop diuretics such as frusemide. We cannot state whether diuretic usage was appropriate or if the symptoms indicating their use were current, although the inappropriate use of diuretics has been previously reported [15]. A recent study which examined the relationship between diuretic use and continence status reported a significantly higher prevalence of urinary incontinence amongst diuretic users with unstable detrusor contractions [16]. Furthermore, as the withdrawal of diuretics appears to be safe for many patients [17], there is clearly the potential for alleviating symptoms of urinary incontinence for some sufferers in residential care. Promotion of continence was good in only one-third of the homes and incontinence management was effective in under half. Many had no coherent strategy on how to promote continence and were not using even simple strategies such as night-time toileting and the use of clear toilet signs. Furthermore, none of the residents in our sample of homes was using pelvic-floor exercises despite their benefit in the treatment of stress incontinence [8]. Ouslander et al. [18] have emphasized the importance of personal targeted night-time visits to the toilet in incontinent patients, and wide clinical experience suggests this is an effective means of controlling night-time incontinence. It is unlikely that such regimes would occur in the absence of daytime toileting which has been shown to be effective in controlling and curing urinary incontinence [19]. Obvious toilet signs and directions to the toilet are frequent requests from those caring for elderly patients [20], but proof that such measures increase continence is lacking. This survey regarded it as good clinical practice if homes had made any attempt to indicate the whereabouts of toilets by the use of large, clear signs or coloured doors, or had made an individualized clinical trial of night-time toileting to alleviate incontinence. Sanford emphasized the importance of not having rigid toileting regimes which might not be tolerated as well as the incontinence [21]. Our results clearly indicated that more help was needed. Furthermore, this was confirmed by the overwhelming request by staff in the homes for support, advice and training. Private sector homes felt unsupported by the NHS and expressed anger about the withdrawal of free continence aids as unfair on their residents and families, to whom most had had to pass on the additional cost. Despite this, between one-fifth and one-quarter had insufficient access to various continence aids. Overall, therefore, the service offered to incontinent residents is failing to meet a serious need. Considerable distress was observed amongst cases, the majority of whom felt depressed or socially restricted by their incontinence. In conclusion, residential and nursing homes for older people require greater input and continuing support from the continence service. Since more than two-fifths of older people in all types of long-term care suffer from urinary incontinence [4], this is clearly a substantial undertaking. Over one-third of cases had external manifestations of the problem due to the insufficient use of aids and poor management. We recommend that a special programme be established for the assessment and treatment of urinary incontinence in residential and nursing homes, including a review of drug therapy. Strategies for promoting continence and managing the problems of incontinent residents in a sensitive manner must be developed. The staff in homes cannot be expected to raise the standards of their continence care without a substantial input from continence specialists. In view of the high degree of difficulty being experienced by the homes and the expressed requests of staff for more help, greater assistance is required if a proper service to incontinent elderly residents of residential and nursing homes is to be provided. 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