Everybody s Business- Continence Promotion in Aged Care Melissa O Grady Clinical Nurse Consultant Continence
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Objectives What is Old Age? What Is Incontinence? Prevalence Of Incontinence Impact Of Incontinence How To We Stay Continent? Transient Causes Of Incontinence Types Of Incontinence
Objectives (continued) When Is A Continence Assessment Required? How Do You Do A Continence Assessment? When To Contact The Doctor
Aged Most developed-world countries have accepted the chronological age of 65 years as a definition of 'elderly' or older person (WHO 2012). However, the developing world often defines old age, not by years, but by new roles, loss of previous roles, or inability to make active contributions to society (WHO 2001)
Forman 1992
Incontinence Incontinence is a term that describes any accidental or involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, faeces or wind from the bowel (faecal incontinence) (CFA website).
Prevalence Incidence of incontinence increases with age: 65% of women and 30% of men over 65yrs in GP waiting rooms have urinary incontinence. Incontinence is estimated to affect 70% of Australians in Residential Aged Care Facilities (RACF). Women > men.
Impact of Incontinence on Quality of Life Significant predictor of admission to RACF. Affects Dignity and Comfort. Social Isolation. Financial Burden.
Financial Implications In 2010 the total financial cost of incontinence in Australia is estimated to be $43.9 billion, or $9,014 per person with incontinence. $270.8 million estimated health system costs. $34.1 billion estimated productivity losses. $1.6 billion estimated residential aged care costs. $2.7 billion estimated informal carer costs. $321 million estimated other indirect costs (aids, formal carer expenses). $3.8 billion estimated deadweight losses from transfers and lost taxation (CFA 2011).
Drips, Slips and Falls Association of incontinence and increases in hospital admissions, morbidity and mortality.
Pelvic Anatomy Female Bladder, uterus and bowel supported by pelvic floor. Pelvic floor is like a muscular trampoline. The ligaments that attach the pelvic floor to the pelvis are like the springs on a trampoline. 3 openings in pelvic floor.
Pelvic Anatomy Male 2 openings in pelvic floor.
Bladder Filling Phase Bladder should fill without a big change in pressure. First sensation to void at approx 150-300mls (or at 90% full and only 10 minutes notice in elderly).
Voiding Phase Strong sensation at 400-600mls (200-300mls in the elderly). Voiding is voluntarily initiated by contraction of the abdomen and relaxation of the pelvic floor muscles. The external sphincter relaxes reduced pressure in the urethra allowing the bladder neck to descend and open. A few milliseconds later the bladder contracts and voiding commences.
Voiding (cont) Simultaneous relaxation of the external sphincter and the bladder neck + contraction of the bladder is necessary for the bladder to empty completely. This is co-ordinated in the brain stem.
Damage to the nerves from the brain to the bladder Leads to either No voiding = urinary retention OR No holding on = urinary incontinence
3 Ms of Continence Motivation Manual Dexterity Mobility
Aging Permanent Incontinence Incontinence (especially new incontinence) must be assessed thoroughly and assumed to be treatable unless proven otherwise. Incontinence products are a last resort.
Transient Causes of Incontinence Delirium Infection-urinary (symptomatic) Atrophic urethritis/vaginitis Pharmaceuticals Psychologic,esp depression Excessive urine output Restricted mobility. Stool impaction.
Infection Irritation causes signals to spinal cord at lower volumes. 4% of RACF population have a recurrent urinary tract infection (UTI)
Atrophic Vaginitis/Urethritis
Pharmaceuticals Stress incontinence - Prazosin, Minipress, Flomax, Duodart, Valium. Relax urethral sphincter Urge incontinence diuretics, Jardiamet, Lithicarb urine production, sedatives. Retention or overflow incontinence anticholinergic agents, verapamil, pseudoephedrine, opiods, psychotrophic medications, nasal decongestants, Ventolin. Functional incontinence - psychotropic medications, analgesics, antihypertensives, sedatives.
Psychologic Depression.
Excessive Urine Output Due to medications. Diabetes Increased oral intake.
Restricted Mobility
Stool Impaction Initially constipation can cause urgency. Dilated rectum bladder relaxation.
Stress Incontinence
Urge Incontinence Due to failure of inhibition of bladder contractions. Can be due to a problem with the nervous system, a bladder infection or some people are born with it.
Functional Incontinence
Overflow Incontinence
When is a Continence Assessment Required When red flags are identified. When a change in continence status is evident. When the resident is admitted to a facility full time, respite or rehab.
Continence Tools For Residential Aged Care: An Education Guide Section A: Toileting ability, cognitive skills and mobility. Section B: Bladder and Bowel pattern Section C: Nutrition (fluids and diet) Section D: Skin Care Section E: Medical Factors Section F: Resident s Perspective Continence Tools RAC (Deacon University/NCMS 2009)
Investigations for Urinary Incontinence Urinalysis, MSU Bladder Scan 3 Day Bladder Chart Time voiding or incontinent Damp/wet/soaked activity when leakage occurred eg coughing, sneezing, standing, constant dribble Urgency
Investigations Bladder Volume of Leakage Intake Diuretics/ aperients Mobility Manual Dexerity
Melissa O Grady, CNC Continence SLHD Nocturia and/or frequency Incontinence Perform a post void bladder scan Volume > 200mls Volume < 200mls Inform RMO. UA +ve Collect a MSU -ve Inform MO Check for constipation If yes Refer to Bowel Flow Chart If no MO to review/adjust medications 3 day Continence Assessment Chart Record patient s functional status including dexterity and flexibility, fine and gross motor skills, cognitive function, treat confusion
Investigations Bowel 7 day bowel chart Bristol Stool Form Guide Type/form/consistency Incomplete bowel evacuation Assisted evacuation Difficulty with wiping Toilet positioning
Normal bowel motions are 3 times a day to 3 times a week as long as bowel motion is formed.
When to Contact Doctor Pain Bleeding Smelly, cloudy, urine Sudden agitation or confusion No urine output Complaints of lump coming out vagina or rectum
Normal Pelvic Anatomy
Bladder Prolapse
Bladder or Uterine Prolapse
Rectal Prolapse
Healthy Aging Healthy Aging describes the ongoing activities and behaviours you undertake to reduce the risk of illness and disease and increase your physical, emotional and mental health. It also means combating illness and disease with some basic lifestyle realignment that can result in a faster and more enduring recovery (Australian Council for Health Physical Education and Recreation 2010)