Incontinence in Long-Term Care Residents with Dementia

Jayna M. Holroyd-Leduc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Clinician-Investigator, University Health Network, Toronto, ON.
Cara Tannenbaum, MD, FRCPC, MSc, Assistant Professor, Department of Medicine, University of Montreal; Director, Geriatric Incontinence Clinic, McGill University Health Centre; Director, Institut Universitaire de Geriatrie de Montreal, Montreal, QC.

Urinary incontinence is a prevalent condition among long-term care residents, particularly those with dementia. The costs and morbidity associated with urinary incontinence are significant. Urinary incontinence can be easily assessed within the long-term care setting. Several modifiable risk factors should be identified and addressed. Effective behavioural treatment options for incontinence exist and several treatment strategies can be used successfully for patients with dementia.

Key words: urinary incontinence, dementia, long-term care, diagnosis, management.

Management of Urinary Incontinence in Older Women

Sue O’Hara, RN, MScN, ACNP, GNC(C), Nurse Practitioner/Clinical Nurse Specialist, Specialized Geriatric Services, St. Josephs Health Care London, Parkwood Hospital, London, ON.; Michael J. Borrie, BSc, MB, ChB, FRCPC, Professor, Department of Medicine, Division of Geriatric Medicine, The University of Western Ontario, London, ON.

Urinary incontinence is a significant problem in older women. Prevalence rates vary from 4.5–44% in healthy older women and increase to 22–90% in patients in long-term care facilities. Canadian Continence Guidelines have recently been developed to assist patients and health care professionals in assessment, treatment and follow-up of urinary incontinence. Urinary incontinence can be treated successfully, improved or better managed in most patients. Treatment falls into four major categories: behavioural, pharmacologic, surgical and supportive measures. Education, the key to effectively addressing the needs of women with incontinence, is aimed at the patient and/or their caregiver, as well as health care professionals.
Key words: urinary incontinence, older women, assessment, treatment, Canadian Continence Guidelines.

Urinary Incontinence in the Elderly

Dr. Lynn Stothers, MD, MHSc, FRCSC, Assistant Professor of Surgery/Urology, Associate Member, Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC.

Dr. Howard Fenster, MD, FRCSC, Clinical Professor, Department of Surgery, Division of Urology, University of British Columbia, Vancouver, BC.

Definitions and Epidemiology
Urinary incontinence (UI), the involuntary loss of urine, is a common medical condition in the elderly. Over 1.5 million Canadians are currently afflicted with the condition, and the number is expected to increase significantly over the next 20 years as the baby boom population ages.¹ Chronic UI has far-reaching consequences for both the individuals affected and their caregivers. Physical complications include renal failure, urinary tract sepsis, renal calculi, hematuria, skin disease, falls and fractures and death relating to renal failure/urosepsis. Psychosocial impact can range from embarrassment and social isolation to depression and suicidal ideation. Less than 50% of those affected seek help for the condition, often due to embarrassment.

Classification
UI can be categorized according to the simple clinical classification presented in Table 1.

Defects in Aspects of the Aging Urinary System have Severe Consequences

Nadège Chéry, PhD
Contributing Author,
Geriatrics & Aging

The human body undergoes important physiological changes as it ages^1,2 and the urinary system is no exception to this trend.³ A major consequence of this decline in urinary function is urinary incontinence, which is defined as the inability to control urination.⁴ Urinary incontinence affects approximately 50% of all nursing home residents and frail, homebound, elderly individuals.³ It may be temporary or permanent, and can result from one of a variety of dysfunctions that occur in the urinary tract.⁴ Urinary incontinence may cause impaired healing of perineal pressure sores and rashes, and may eventually lead to psychosocial effects, including embarrassment, social isolation and depression of the affected elder.³

The pathophysiology & clinical presentation of urinary incontinence
Urinary incontinence results from defects in neurologic or anatomic aspects, and it is these defects that interfere with normal urinary micturition.⁴ Alteration of the normal contraction and emptying of the bladder is one important cause of urinary incontinence. Normally, both the somatic and the autonomic nervous system innervate the bladder. The relaxation and filling of the bladder are both under sympathetic control, which produces an increase in the b-adrenergic tone of the bladder.

Part 6: Urinary Incontinence--A Guide to Product Selection

Sonya Lytwynec, RegN, BScN
Nurse Clinician,
Southwestern Ontario Regional Geriatric Program,
Continence Outreach

Urinary incontinence can be successfully treated in some individuals.¹ There are, however, many individuals who remain unresponsive to behavioural, medical or surgical treatment and continue to experience chronic urinary incontinence. These individuals can benefit from improved continence management, using incontinence products that enable them to maintain social acceptability, skin integrity and comfort.

The focus of this article is to identify the factors that influence product selection and describe the key features of products that may guide the health care professional in meeting the specialized needs of individuals and caregivers.

Incontinence products may be utilized in addition to other treatment modalities to promote comfort and security. For example, supplementing toileting protocols with the use of absorbent disposable diapers and moisture barriers may be effective in reducing the risk for skin breakdown.²

Selecting the most appropriate product can be a complex task.

Functional Urinary Incontinence--Part V of V

Sonya Lytwynec RegN, BScN
Michael J Borrie BSc, MD, ChB, FRCPC
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Functional urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with functional incontinence are reviewed in this fifth and final article of a five part series on urinary incontinence. Functional incontinence is defined as the involuntary loss of urine associated with the inability to use the toilet because of impairments of cognitive or physical functioning, psychological unwillingness or environmental barriers.²

The existence of urinary incontinence has been estimated at 15% to 35% in community dwelling people over 60 years of age, with twice the prevalence in women compared to men. The prevalence increases to 53% in homebound individuals, and is reported at 30% in acute care hospitals and 40% to 60% in longterm care institutions.³ A study of incontinent people receiving home care services (mean age 74) reported that a total of 89% had at least one functional disability (cognition, mobility, transferring in and out of bed or chair, or undoing garments). The incontinence was moderate to severe in 41% of the patients, and 95% of the family caregivers viewed the incontinence as a problem.⁴

Functional incontinence should be a diagnoses of exclusion.

Overflow Incontinence--Part IV of V

Sonya Lytwynec, RegN, BScN,
Hassan Razvi, MD, FRCSC,
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Overflow urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with overflow incontinence are reviewed in the fourth article of a five-part series on urinary incontinence. The first article in this series provided an overview of the prevalence, types, and treatment of incontinence in the frail elderly.

Overflow incontinence is defined as the involuntary loss of urine associated with over-distension of the bladder.² It is reported to comprise up to 30% of diagnoses in a geriatric continence clinic.³ Aging is associated with several physiologic and anatomic changes to the urinary tract which may predispose the older person to overflow incontinence. Both bladder outlet obstruction and detrusor muscle weakness may manifest alone or in combination as overflow incontinence. It has been estimated that up to 60% of men between 70 and 87 years of age develop clinical symptoms of benign prostatic hypertrophy (BPH).¹ BPH is the most common cause of voiding dysfunction in elderly males and may first present as urinary retention and overflow incontinence. Overflow incontinence occurs less often in women, but may develop following pelvic surgery or as a result of pelvic organ prolapse.

Urge Urinary Incontinence--Part III of V

Sonya Lytwynec, RegN, BScN,
Michael Borrie, BSc, MB, ChB, FRCPC
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Urge urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with urge incontinence will be reviewed in this third article of a five-part series on urinary incontinence. The first article in this series provided an overview of the prevalence, types and treatment of incontinence in the frail elderly; the second discussed stress urinary incontinence.

Urge incontinence is defined as the involuntary loss of urine associated with the urgency to void. It is the most common type of incontinence in those individuals over the age of 60. Several studies report that urge incontinence occurs predominantly in men (73.3%), followed by mixed incontinence (19.1%), and stress incontinence (7.6%). The prevalence of urge incontinence in women is reported at 22%, and mixed incontinence at 29%.² Older women often experience combined symptoms of stress and urge incontinence called mixed incontinence. Patients with urge incontinence often suffer severe emotional distress, social embarrassment and isolation.

The severity of urge incontinence symptoms vary from occasional urine losses on the way to the bathroom to sudden, uncontrollable "flooding" without warning.

Stress Urinary Incontinence--Part II of V

Sonya Lytwynec, RegN, BScN
Nurse Clinician, Southwestern Ontario Regional Geriatric Program: Continence Outreach

Stress urinary incontinence (SUI) is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with stress incontinence will be reviewed in this second article of a five-part series on Urinary Incontinence.

SUI is defined as urine loss coincident with an increase in intra-abdominal pressure in the absence of a detrusor muscle contraction or an over-distended bladder.² SUI is a term used in reference to symptoms, physical findings or conditions. Coughing, sneezing, laughing, lifting, or bending over along with simultaneous urine loss often indicates SUI. However, in complex or unresolved cases, urodynamic testing may be beneficial to differentiate between SUI and other types such as urge incontinence.

Prevalence studies report variable results according to definition and design. Subjective reports of SUI in community-dwelling elderly women (65 years of age or older) ranged between 12% and 17%, while urodynamic studies at a urological clinic estimated prevalence rates of SUI at 16% for females and 2% for males.³

SUI in males is commonly the result of intrinsic sphincter deficiency (ISD) post prostatectomy.

An Introduction to Urinary Incontinence--Part I of V

Michael J. Borrie, BSc, MB, ChB, FRCPC
Chair, Division of Geriatric Medicine, The University of Western Ontario

Prevalence studies of urinary incontinence in the elderly report widely-varying rates from 4.5-44% in healthy, elderly women to 4.6-24% in healthy, elderly men. The prevalence in institutionalized people ranges from 22-90%.¹

Choice of definition, wording of the questionnaire and study population contribute to this variability. The International Continence Society has defined incontinence as a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrated.² Based on the symptom complex, urinary incontinence is characterized as urge, stress, mixed, overflow, functional, or iatrogenic.

Urgency urinary incontinence is the most common type and is divided into sensory or motor urgency. Ambulatory or longer-term urodynamic studies have demonstrated involuntary detrusor contractions and calls into question the notion of sensory urgency. A new classification of overactive bladders has been proposed but has not yet been resolved.³ Detrusor instability is commonly associated with neurologic conditions such as stroke or Parkinson's Disease. It can also accompany prostatic obstruction.