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1 Welcome to the second of our two modules, Continence: A Matter of Dignity, Care of Chronic and Complex UI. We are here today to discuss a topic which, every day, affects our jobs and lives of those we care for the challenges of Continence Care when UI is chronic and complex. Our goal is to achieve and maintain the best possible levels of continence in elderly persons. By helping to avoid accidents, each of us can greatly promote the dignity and quality of life of the older adults under your care. Delaware Valley Geriatric Education Center 1

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4 In the Causes, Signs and Prevention module on urinary incontinence or UI we covered four major objectives as intended outcomes for learners. Let s quickly review those with you before we begin the second module. Participants will be able to: 1. List the common causes of urinary incontinence including age related changes, illnesses and disorders. We talked about the fact that limitations i i in function, including difficulty getting to the bathroom and removing clothing in time to prevent an accident, are the most common causes of UI. 2. Describe the potentially serious effects of not treating UI including skin breakdown, falls, injuries, infections and even death. 3. Recognize the major signs of a UTI in the older adult so you can report it promptly and prevent it from becoming far more serious. 4. Discuss effective ways to prevent or reduce episodes of UI and to enhance dignity. A good place to start is by keeping a log of accidents and the time each happened. This may show a pattern that can be used to make a schedule for assisting and prompting (which means suggesting, encouraging and reminding) the older adult to toilet. Remember, that each time you help a person to be continent, you greatly enhance his or her dignity. Delaware Valley Geriatric Education Center 4

5 After Care of Chronic and Complex Urinary Incontinence you will be able to: 1. List the major types of chronic urinary incontinence or UI and the commons signs and symptoms of each. 2. Explain the importance of preventing constipation in the older adult with UI. 3. Discuss creative approaches to more complex cases of older adults with ih UI. 4. Help provide care to prevent or reduce episodes of UI and enhance the dignity of those in your care. Delaware Valley Geriatric Education Center 5

6 There are four major types of chronic or long-standing urinary incontinence. 1. Stress incontinence 2. Urge incontinence also known as Over Active Bladder or OAB 3. Overflow incontinence 4. Functional incontinence A fifth group called mixed is a combination of any two or more types. Let s look at the four major types and their common characteristics. Delaware Valley Geriatric Education Center 6

7 Stress UI in older adults is caused by weakness of the muscles that close the bladder. As a result, in the early stages of stress incontinence, a small amount of urine leaks out with certain activities such as sneezing, coughing, laughing, bending, and lifting. Later, leaking occurs more frequently and with less activity. People with stress UI seldom have very much in the bladder, and over time, the bladder shrinks so it can hold less and less. People with stress UI report the need to go often, and they may have a sense of pressure in the lower abdomen. Delaware Valley Geriatric Education Center 7

8 The best approach to stress incontinence is to prompt (that is, to suggest, encourage and remind) the person to go to the bathroom on a schedule. Figure out the older adult s routine by using a log like the one in your handouts to write down the time of each accident or incontinent event. Then look to see how far apart the events usually occur. That amount of time can tell you how often the person may need to go to the bathroom. Try to match that schedule as often as possible. You may quickly find that you can keep the person continent and dry much longer, which in turn can enhance his or her dignity. Small leaks can still occur, so it may be helpful to use a liner in the older adult s underwear. Delaware Valley Geriatric Education Center 8

9 Always change wet garments as soon as possible. Keep the skin clean and always use a skin barrier. A skin barrier is a coating of ointment which creates a waterproof barrier on the skin (example: A&D ointment). Women with Stress UI will often benefit from estrogen placed in the vagina to restore tissues that have been weakened by the loss of estrogen after menopause. Encourage the person to eat wellbalanced meals in order to help maintain skin integrity. CASE EXAMPLE Mrs. Levy became frustrated and embarrassed when she leaked a small amount of urine each time she coughed. hd Fortunately, she hd had a sensitive caregiver who knew how embarrassing this can be. Her caregiver helped her develop a toileting schedule to reduce the episodes and introduced her to liners. Delaware Valley Geriatric Education Center 9

10 The older adult with Urge UI, also called Overactive Bladder or OAB, has a strong urge to urinate and a need to get to the bathroom or commode quickly. The person is generally unable to delay for any length of time and often will be incontinent on the way to the bathroom. The amount of urine passed tends to be greater in Urge UI than in Stress UI, with longer periods of dryness. CASE EXAMPLE Mrs. Powell, whom you will meet in the next video, often has a very sudden urge to urinate. She uses a walker and can be heard shouting for help to come quickly and assist her to a bathroom. She has had several accidents because she was not able to reach the bathroom in time. She feels more frustrated and helpless with each accident. Delaware Valley Geriatric Education Center 10

11 Since the bladder is already hyperactive, it is important to encourage the person to avoid bladder irritants such as caffeine, alcohol and artificial sweeteners. The person preparing meals and snacks needs to know as well. You can also help by establishing a toileting schedule and sticking to it, watching for signs of a need to toilet, and keeping a urinal or commode close by. Using the following introduction, i show Video Scenario Mrs. Powell s Success : We are now going to show you a video clip. Remember Mrs. Powell with symptoms of Urge Incontinence? We ll see how the caregiver has helped improve her quality of life. {go to next slide} Delaware Valley Geriatric Education Center 11

12 Instructor: Double click on black square to start video segment Mrs. Powell s Success. Or use right hand button on mouse, and click on Play movie. Adjust volume. OR Insert Video into VCR, start video tape at fourth scenario of tape to play Mrs. Powell s Success Delaware Valley Geriatric Education Center 12

13 Let s review what we learned from Mrs. Powell s situation. Delaware Valley Geriatric Education Center 13

14 Overflow UI occurs when the bladder is not able to empty. The bladder continues to fill until the tension inside the bladder forces the muscle open at the base of the bladder. A small amount leaks out, relieving the pressure for the moment, but the bladder cannot empty completely. There may be continuous or periodic leakage of small amounts of urine. Overflow UI can be caused either by: 1.) blockage of urine flow at the base of the bladder as can be seen with prostate enlargement 2.) damage to the bladder muscle or to the nerves controlling bladder function Common causes of this type of overflow UI or diabetes or spinal cord injury. The condition of left over urine which does not empty with voiding is called urinary retention. Patients with urinary retention and overflow UI may stand a long time before being able to void and then only release a small amount of urine. If you see this kind of difficulty, report it. There are some medications that can help. In more severe cases, surgery may be necessary. CASE EXAMPLE Lately, Mr. Stanley, has been going to the bathroom more often. He takes a very long time to start to urinate and then only goes a little bit. He says he never feels empty. He often leaks a small amount between toileting or dribbles a bit after he finishes. This is typical of an older adult man with a large prostate. Delaware Valley Geriatric Education Center 14

15 For older adults with overflow incontinence, it is important to keep the skin dry as much as possible. Wearing underwear with a liner is best for the skin. Allow the older adult plenty of time to toilet and report any of the following: If the person complains of abdominal pain or not feeling empty after toileting If the person has not urinated in the past eight hours (unless the older adult is on dialysis) If the need to urinate is happening more often If there are changes in mental status, such as increased confusion Delaware Valley Geriatric Education Center 15

16 Functional UI is not due to any problem with the bladder or the kidneys. It is simply the physical inability to complete any one of the steps in using the bathroom OR the mental inability to know what the urge to go means or to remember where the bathroom is located. CASE EXAMPLES Mr. Clark has Alzheimer s disease. He sometime urinates into a trash can. WHY? because he senses his need to go but probably cannot remember what to do about it because he cannot remember where to find the bathroom or because he confuses the trashcan with the toilet t We ll see Mr. Clark in a video later. On the other hand, Mrs. Lee knows when she needs to go and knows where to find the bathroom, but because of arthritis of her hands, cannot manipulate her clothing fast enough to avoid an accident. Both Mr. Clark and Mrs. Lee have functional incontinence. Delaware Valley Geriatric Education Center 16

17 This type of incontinence is often most treatable. Set individualized toileting schedule based on the log and stick to it. Encourage use of clothing that is easier to remove quickly when the older adult feels an urge to go. Provide whatever assistance is necessary in traveling to the bathroom, removing clothing, standing or transferring and cleaning up and replacing clothing afterwards. Always praise the older person when successful. If unsuccessful, always praise the effort. Delaware Valley Geriatric Education Center 17

18 Providing care to some older adults with functional UI or other problems may be more complicated. Some situations are very complex and challenge us as caregivers to be creative in helping people be more continent. These challenging situations include older adults with dementia (inappropriate toileting, denial of incontinence), unsafe attempts to toilet and chronic constipation. I want to talk a little bit about each of these cases and offer some suggestions for care. Delaware Valley Geriatric Education Center 18

19 It is a common misconception that incontinence is incurable with dementia. Older adults with dementia may still sense the need to toilet but may be unable to find the bathroom or remember its purpose. Others may only be aware of the need to toilet if asked or prompted. They still may associate toileting with a receptacle; as a result, some older adults may urinate in inappropriate places such as a potted plant or cup. CASE EXAMPLE Mr. Clark gets confused and uses the trash can. The fact that he attempts to place the urine in a container tells you that he still senses the need to toilet. Others may be incontinent but forget immediately they have had an accident ; they then deny that they are wet or that they have been incontinent. Delaware Valley Geriatric Education Center 19

20 It never helps to judge or disagree. Never insist that he or she remember or accept that the wet clothing is due to urinary incontinence. Simply reassure the person and recognize the situation. For example, say something like, You must be uncomfortable with those wet clothes. Let me help you change. On the way, you can suggest a stop in the bathroom. Once you are there, prompt the older adult to urinate. It is helpful l to prompt the person who urinates inappropriately. i Ask the person, Do you need to go to the bathroom? Or suggest that it is time to go and escort the person to the bathroom or commode, or assist to use the urinal. You may be surprised at how often the prompting works. Remember to prompt again when you get to the bathroom or commode, because by then the older adult with dementia may already have forgotten why he or she is there. Using the following introduction, show Video Scenario Right Time, Right Place : We are now going to show you a video clip. Mr. Clark gets confused and uses the trash can. We ll see how the caregiver uses prompting and encouragement and keeps the focus on dignity and respect. {go to next slide} Delaware Valley Geriatric Education Center 20

21 Instructor: Double click on black square to start video segment Right Time, Right Place. Or use right hand button on mouse, and click on Play movie. Adjust volume. OR Insert Video into VCR, start video tape at fifth scenario of tape to play Right Time, Right Place Delaware Valley Geriatric Education Center 21

22 Mr. Clark s situation reminds us to focus on: Dignity it and respect Changing and cleaning Focus on Changing and cleaning Dignity and respect Prompt (remind and encourage) to use the toilet, assist to get there, then prompt again Delaware Valley Geriatric Education Center 22

23 Unsafe attempts to toilet are all too common among older adults and are one of the leading causes of injuries including fractures. These attempts may be due to a number of things. Difficulty in walking can make toileting unsafe. Poor eyesight or the wrong glasses may also increase the safety risk, especially if the older adult is in a hurry. If the person feels an urge to urinate and cannot wait, he or she may attempt to go to the bathroom without needed assistance because staying dry is so important to his or her sense of dignity. The person may no longer be making safe decisions due to dementia or other cognitive impairment. Delaware Valley Geriatric Education Center 23

24 When a person has made repeated unsafe attempts to go to the bathroom the best approach is to have an individualized toileting schedule that occurs more frequently than the attempts. In this way you can anticipate the need and be there ahead of time. Older adults taking diuretics or water pills will need to urinate much more often in the hours after taking the pill. The number of hours will depend on the individual and the effect of the medication on his or her system. Get to know that effect by keeping track of these episodes for a few days and then try to toilet according to that schedule. A call bell is useful if you are in a setting where one is available. For the person with memory impairment, however, this is of little value. The person will not remember how to use the bell or the reason for calling. On the other hand, if the person does remember and rings a call bell, it is extremely important that you answer it promptly. Even a short delay may cause the person to make an unsafe attempt to go to the bathroom alone. Delaware Valley Geriatric Education Center 24

25 It is also important for those at risk to use safe footwear that will not slip. If the person you are assisting is wearing glasses, be aware of potential problems. For example, reading glasses or bifocals can each cause problems in judging distance. Always be ready to assist or walk beside a person with bifocals if the glasses cause them to misjudge distance. A bedside commode can be used for someone who cannot safely walk a distance but can safely stand and transfer without assistance. For men, be sure to have a urinal within reach. This can reduce the need to walk alone or to make an unsafe attempt to get to the bathroom. Delaware Valley Geriatric Education Center 25

26 Constipation among older adults is very common. It can cause the person to have UI that is new or worse than before. This happens because the stool in the bowel takes up room in the pelvis and leaves the bladder less room to expand. As a result, the bladder can hold less urine and the person has to go to the bathroom more often. Delaware Valley Geriatric Education Center 26

27 There are several things you can do to help. Begin by reporting chronic constipation so that it can be treated. Next encourage fluid intake. Constipation is often caused by a lack of fluid. Encourage regular walking activity if possible. If you help with diet selection, encourage foods with fiber such as fresh fruits and vegetables,,juices and cereals. Discourage foods that are constipating such as white bread and cheese. Caffeine can be an AM laxative. Finally, be sure to prompt and assist with toileting more often until the constipation is corrected. This concludes the section on challenging cases. Let s review the objectives for this module as a way of summarizing i what we ve learned. Delaware Valley Geriatric Education Center 27

28 In Conclusion During this presentation we have covered the three major objectives. Can you now 1. List the major types of chronic UI and the presentations of each? We discussed Stress, Urge, Overflow and Functional Incontinence as well as Mixed UI which is simply a combination of two or more. 2. Explain the importance of preventing constipation in older adults with UI? The bowel, when distended or overfilled, can press against the bladder and limit how much it can expand. As a result constipation can lead to increased frequency and, therefore, incontinence. 3. Discuss creative approaches to more complex cases of urinary incontinence in older adults? Specifically we reviewed what you can do to care for UI in the person with dementia, especially those who toilet inappropriately or deny accidents, as well as those who make unsafe attempts to toilet and those who are chronically constipated. With this information you are now better prepared to take care of older adults with UI in a manner that is dignified and that ultimately enhances the older adult's quality of life and that of staff and family. Delaware Valley Geriatric Education Center 28

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