U

rinary incontinence (UI), the involuntary loss of urine, is a significant health problem in the extend care setting. It affects approximately 60 percent of assisted living residents and 70 to 90 percent of nursing home residents¹. Erroneous perceptions that UI is a normal part of aging or that treatment options are ineffective have a deleterious impact on the quality of life of our residents. UI leads to embarrassment, depression, and social isolation. It has been eloquently expressed, “Incontinence doesn’t kill you; it just takes your life away.”
       Fortunately, several agencies have developed best practice guidelines to improve recognition, assessment, and treatment of UI. By applying these guidelines, facilities and participants can anticipate a reduction in the frequency and severity of UI episodes, prevention of complications, such as skin irritation and urinary tract infections, and improvement in the residents’ quality of life.

Preparing the Facility to Implement Best Practice Guidelines^2–5
       The facility and residents can treat UI successfully with adequate planning, administrative support, and active involvement of key clinical staff. Initially, the facility should review current policies and procedures for UI. Revisions and approval may need to be completed. Conduct an environmental readiness assessment. Determine adequacy of grab bars, transfer devices, elevated toilet seats, bedside commodes, etc. Needed resources should be secured before attempting to implement a prompted voiding (PV) program.
       Although PV is a simple, noninvasive intervention, it is labor intensive. Therefore, it is essential that all staff, especially direct care staff, receive encouragement and support. Pointing out accomplishments of various clinical trials can be motivating. For example, in one trial, 33 to 60 percent of residents reduced the frequency of their incontinence to one episode per day or became continent after participating in the program⁶.
       Next, educational programs for PV should be devised and presented to all levels of healthcare providers. The programs should include the risk factors for UI, complications of UI, and effective management of and documentation for UI (assessment, bladder records, and PV program).

Implementing the Program^2–5
       Execute the PV program gradually. Involve direct care staff in goal setting for program implementation and selection of residents likely to benefit from the program. Begin with residents who are likely to have a positive response so that team members, including the resident, may celebrate their accomplishments. Start with residents who are more cognitively intact, have greater ability to ambulate/transfer, have baseline incontinence less than 4 times/12 hours, recognize the need to void, have a high number of self-initiated requests (SIRs) to toilet, are able to void successfully when given toileting assistance, and/or have good bladder functioning (normal bladder capacity > 200cc and < 700cc; maximum voided volume > 150cc; and post-void residual < 100cc).
       The best predictor of an individual’s response to PV is his or her success to a therapeutic trial of PV. Many people responsive to PV show a clinically significant increase in appropriate toileting behavior and continence levels during a three-day trial. Maximal response to the treatment may not be realized until after several weeks of PV. Signs of positive responses include wet percentage less than 20 percent during the first three days of PV, appropriate toileting greater than 66 percent during the first three days of PV, and/or at least 50 percent of voids into toileting receptacle during first day of PV.

Step 1—Recognize Urinary Incontinence
       The first step in implementing a PV program is to review the resident’s history of UI. Validate levels of urinary control with direct care staff. Make sure all caregivers understand and use the same definition of UI. Often, caregivers do not consider residents who “dribble” or who have “accidents” as incontinent. This confusion was clarified in the Revised Long-Term Care Resident Assessment Instrument User’s Manual (page 3-120) as follows: “If the resident’s skin gets wet with urine, or if whatever is next to the skin (i.e., pad, brief, underwear) gets wet, it should be counted as an episode of incontinence—even if it’s just a small volume of urine, for example, due to stress incontinence⁷".

Step 2—Conduct Incontinent Assessment
The following assessment items are recommended for all incontinent residents:
• History of incontinence
– Duration
– Most bothersome symptom(s) to the resident
– Frequency, timing, and amount of continent voids and incontinent episodes
– Precipitants of incontinence (e.g., laugh, cough, sneeze, getting to the bathroom, surgery, injury/trauma/illness, new medication)
– Other urinary tract symptoms (e.g., nocturia, pain, hesitance, straining, interrupted stream, enuresis)
– Amount and type of perineal pads or protective devices
– Previous treatments and effects on UI
– Expectations of treatment
• Mental status assessment
– Cognition—if delirium (acute confusion) is present, treat underlying cause of delirium
– Awareness to void
– Motivation to be continent
– Depression
• Functional assessment
– Level of mobility
– Ability to transfer
– Manual dexterity
– Physical restraints
– Chemical restraints
• Environmental barriers
– Access and distance to toilet
– Chair/bed allow ease when rising
• Food and fluid intake
– Ensure an adequate level of fluid intake (1500–2000mL per day) and eliminate the use of caffeinated (teas, coffee, colas) and alcoholic beverages
– Dietary intake, including fiber
• Bowel habits
– Frequency of bowel movements
– Addressing constipation/fecal impaction
• Medical/surgical history—Any relevant medical or surgical history that may be related to the incontinence problem, such as diabetes, neurological disorders (stroke, Parkinson’s disease), recurrent urinary tract infections, or previous bladder surgery
• Medications—Many medications can affect the bladder or urethra and result in incontinence (e.g., diuretics, sedative hypnotics, drugs with anticholinergic properties [antipsychotics; antidepressants; narcotics; medications for Parkinson’s disease, except carbidopa-levodopa and selegiline; disopyramide; antispasmodics; antihistamines], calcium channel blockers, and drugs that stimulate or block the sympathetic nervous system)
• Presence of urinary tract infection
• Other contributing factors—Resident conditions (pain; excessive or inadequate urine output; atrophic vaginitis; cancer of the bladder or prostate; urethral obstruction; disorders of the brain or spinal cord; tabes dorsalis); abnormal lab values (elevated blood glucose or calcium).

Step 3—Decide If Laboratory Testing is Appropriate
       Laboratory testing may not be indicated if the resident has a terminal or end-stage condition, if the information gained would not change the management course, or if the resident refuses treatment. Always weigh the burden of the testing against the potential benefits of the treatment.
Optional tests, as appropriate, include urinalysis, urine culture and sensitivity, glucose, calcium, vitamin B-12, urine cytology, post-void residual determination, and urodynamic tests (e.g., stress tests and filling and voiding cystometry).

Step 4—Reduce/Eliminate Causes of Incontinence if Possible
       If the above assessment uncovers causes that can be reduced or eliminated, steps to do so should be implemented. For instance, if the assessment reveals the resident’s incontinence started after beginning nifedipine (a calcium channel blocker) for mild hypertension, another medication that would not cause incontinence might be easily substituted. Conversely, a medication for arrhythmia may not have an appropriate substitute. Of course, consult a team member with prescriptive authority for these decisions.
       It may not be possible to eliminate causes of incontinence. When this happens, consider interventions that may reduce contributing factors. For example, a resident with limited mobility may benefit from transfer training, ambulation/strengthening exercises, or a bedside commode. Essentially, if the resident has any factors contributing to incontinence, the interdisciplinary team should provide individualized interventions.

Step 5—Complete a Bladder Record to Identify Resident’s Voiding Pattern
       Completing a three-day bladder record, voiding diary, or other type of monitoring system can help identify individual patterns of UI. In one study, researchers used an electronic data logger to record exact times of voiding: 85 percent of the subjects in this study were found to have regular voiding patterns over the three-day data collection period⁶. Another study using a paper monitoring system and an hourly checking schedule identified individual voiding patterns in a significant number of elderly female nursing home residents within two weeks of initiating the monitoring system⁶.
       Based on the three-day bladder record, experts recommend individualizing the PV schedule to meet the toileting needs of the person with UI. The identification of individual voiding patterns can promote the highest level of continence for the incontinent person while minimizing the caregiver time required for completion of the intervention. Rather than attempting to find the toileting schedule that best meets the needs of the individual, facilities may attempt to toilet (i.e., assist to commode, provide urinal) everyone on an every two-hour schedule. However, some people respond best to an every three- or four-hour toileting schedule. Persons who respond to PV early in the intervention are able to decrease toileting sessions from every two hours to every three or more hours. The longer time period between scheduled PV sessions will enable staff to complete other nursing interventions.

Step 6—Make Staff Aware of Residents’ Voiding Needs
       Once regular voiding patterns have been identified, caregivers need to be made aware of this pattern. Posting the individualized toileting schedule in a convenient location and on the resident’s care plan has helped some facilities maintain high levels of continence for extended periods of time.

Step 7—Provide Interventions to Meet Residents’ Voiding Needs
Interventions may include the following:
• Develop an individualized plan of care. This plan is based on information obtained from the assessment and in collaboration with the interdisciplinary team members, including the resident and significant others. Tailor the care plan to the needs and characteristics of the resident with dementia, immobility, etc.
• Provide residents with usual undergarments in expectation of continence, if possible. Use absorbent products (i.e., pads/briefs) judiciously.
• Prevent skin breakdown. This can be accomplished by providing immediate cleansing after incontinent episodes and applying barrier ointments.
• Conduct regular head-to-toe skin assessments. At a minimum, assess skin integrity weekly to identify areas of irritation or breakdown.
• Adhere to the PV schedule and technique.
– Approach person at scheduled PV time (15 minutes before or after assignment is acceptable)
– Greet individual
– Wait five seconds for individual to SIR to toilet
– Ask person if he or she is wet or dry
– Physically check person to determine continence status
– Give social feedback: Praise, if dry; no comment, if wet
– Prompt individual to toilet (regardless of continence status)
– Offer person assistance with toileting
– Give social feedback—praise desired toileting behavior
– Inform individual of the time of next scheduled PV session
– Encourage individual to hold urine in bladder until next scheduled PV session
– Encourage individual to SIR to toilet, as needed—if the resident has a SIR to void at an unscheduled time, immediately assist the resident to the toilet
– Record results.
       Individuals unable to maintain urinary continence with at least an every two-hour toileting schedule after a thorough trial (4 to 7 weeks) of PV are not likely to respond to additional experience with the intervention. If the incontinent individual needs to be toileted more frequently than every two hours in order to maintain continence, he or she should discontinue PV. A scheduled toileting plan augmented with incontinence aids and further evaluation for causes of and treatment for UI is recommended.

Step 8—Evaluate Residents’ Responses to the Program
       Monitor incontinent residents regularly to determine if they are achieving the stated care plan goals. Positive outcomes of PV treatment include:
• Resident satisfaction with treatment
• Increase in daily average number of dry checks/non-wet episodes
• Increase in average volume of continent voids
• Decrease in average volume of incontinent voids
• Identification of individual patterns of UI
• Resident recognizes urge to void.
       Residents who respond favorably should continue the toileting program. If a resident does not respond favorably and is a candidate, consider further treatment options, including behavioral therapy, drug therapy, surgical treatment, electrical stimulation, intravaginal support devices, pads and external collection devices, intermittent catheterization, and/or chronic indwelling catheters. If the resident has no memory recall and is extensively dependent in self transfer, the resident may have difficulty responding and might not be an ideal candidate for further treatment⁷.
       Drug therapies include anticholinergics/bladder relaxants (for urge incontinence), alpha-adrenergic antagonists and estrogen (for stress incontinence), and alpha-adrenergic antagonists (for incontinence in men suspected of having benign prostatic hypertrophy). Drug therapy should be initiated at the smallest recommended dose and slowly titrated upward based on resident response and tolerance.

Step 9—Evaluate the Facility’s Adherence to the Program
       Once implemented, adherence to the program should become part of the facility’s continuous quality improvement efforts to assure compliance to the program.

Conclusion
       Causes of UI can be reduced or eliminated if residents are accurately assessed. Recognition and noninvasive techniques are key to restoring a resident’s normal bladder function. While adhering to the protocol is labor intensive, it can be equally rewarding for the staff and resident. Imagine the satisfaction of hearing an incontinent resident say, “Incontinence—not fun, but you can still have a life.”