Urinary incontinence in long-term care can be improved with proper evaluation and treatments, including medication, evaluated as much for safety as for efficacy.

A

lthough the long-term care market’s nursing facilities and assisted living facilities (ALFs) provide care for a relatively small percentage of the overall US population (0.6%), its residents are disproportionately heavy users of the healthcare system. Only 5% of those aged 65 years and above, but nearly a quarter (22%) of those aged 85 and above, live in a long-term care facility. Therefore, the likelihood of living in a nursing facility increases with age. In fact, the elderly are the highest users of prescription medications, and long-term care residents are the most frail and debilitated of the elderly. The approximately 2.5 million long-term care facility and ALF residents represent approximately $8 billion in pharmaceutical purchases (3.5% of total US prescription spending).¹
       The most significant determinant of long-term care placement is an individual’s need for assistance with basic activities of daily living (ADLs)—activities that are necessary for basic personal care. In fact, between waking up and leaving home to go to work, we are primarily focused on performing these very basic ADLs (eg, transferring or ambulating from bed to standing and walking to the bathroom, toileting, bathing, dressing and grooming, and eating) without much conscious thought. But progressive physically or mentally debilitating disease affects these basic care activities. In general, greater need for assistance to perform these basic ADLs (either in degree or number) requires a higher the level of care (ie, placement in a nursing facility rather than an ALF).
       Clearly, urinary incontinence (UI) often reflects an elder individual’s inability to toilet (with or without assistance) and can lead to institutional placement. In elder individuals, the need for frequent toileting (during the day and at night) and the urgent and/or frequent need to void have been shown to increase the risk of falls by as much as 26% and bone fracture by as much as 34%, particularly in those also suffering from osteoporosis.^2,3 Incontinence and falls with fractures are among the most common causes of long-term care facility admissions. Thus, UI has both direct and indirect adverse consequences for frail elderly individuals.

Prevalence

       With more than 80% of nursing facility residents requiring assistance with toileting, UI is a major problem in the long-term care environment.⁴ The prevalence of overactive bladder (OAB) and associated UI increases with age.^5,6 Nearly 60% of nursing facility residents are reported as having occasional, frequent, or total incontinence.⁷ Many of these residents (34%) are repeatedly incontinent, with 17% experiencing frequent and 8% experiencing occasional UI episodes.⁸ An additional 7% of residents are identified as usually continent with incontinent episodes occurring once a week or less.⁸
       Many factors in long-term care may contribute to UI, including staffing shortages, inattention to individual toileting schedules, and inadequate staff training. Additionally, few nursing facility residents (roughly 2% of incontinent residents in facilities versus 5% for community-dwelling persons) receive appropriate medical evaluation and treatment for UI.⁹ The most common approach to UI in the long-term care facility involves the use of incontinence pads and diapers.¹⁰
       Urinary incontinence can be exacerbated by facility practices like “just putting a diaper on someone” rather than evaluating and treating the underlying causes.¹⁰ Whether it is due to age-related changes or facility practices, the incidence of UI increases with the length of stay, as evidenced by a study showing that of 430 new admissions to a long-term care facility, 22% of women who were initially continent became incontinent within a year.¹¹ There are 5 types of UI:
• Stress incontinence
• Overflow incontinence
• Urge incontinence
• Mixed incontinence
• Functional incontinence.
       Urge incontinence, the involuntary loss of urine associated with a strong and urgent desire to void, is usually associated with involuntary contractions of the detrusor muscle in the bladder, known as detrusor overactivity (ie, OAB, the most common cause of UI in the elderly) accounting for 40–70% of cases.¹² Stress incontinence (ie, the loss of urine due to an increase in external pressure on the bladder from coughing, laughing, straining, or positional changes) is also common in the elderly.

Assessing and Treating Urinary Incontinence in the Facility

       Federal Tag 315 (Tag F315), nursing facility regulatory guidance released in June 2005, was revised to ensure that a

Table 1

resident with UI receives appropriate treatment and services to prevent urinary tract infections (UTIs) and restore as much normal bladder function as possible (see Table 1 for a Centers for Medicare & Medicaid Services list of items a facility should assess before developing a care plan and treatment protocol).
       The comprehensive UI assessment should include medical conditions as well as medications that may affect continence. Medical conditions and medications with a negative impact on continence should be addressed.

Diseases Contributing to Urinary Incontinence

       Mental disorders are most prevalent diagnostic category in the nursing facility population.⁸ More than 70% of nursing facility residents have conditions such as depression (43%) and dementia (55%), causing disorientation or impaired cognition These conditions may prevent an individual from finding the toilet before becoming incontinent. Depression may lead to apathy and reduce the motivation to remain continent. Restraints used to manage behavioral disorders or correct neurological or muscular defects may interfere with mobility and the ability to reach the toilet. Similarly, conditions like cardiovascular disease or stroke affecting functional status—which may impact 20% of residents—can impede successful toileting.⁸
       Incontinence primarily due to factors that impede access to bathrooms is referred to as “functional” incontinence.¹³ Functional incontinence, which may occur after a major illness or institutionalization, accounts for 25% of the incontinence in hospital patients. Sensory impairments (including poor vision, hearing, or speech that impair toileting or the ability to notify caregivers of the need to toilet) can also be causes of functional incontinence. Environmental factors like a relatively inaccessible bathroom may also cause functional incontinence, as may decreased mental function, decreased functional status, and/or unwillingness to toilet.¹⁴ Other factors affecting urinary incontinence follow.
       Parkinson’s disease, Alzheimer’s disease and other types of dementia, stroke, brain masses, and multiple sclerosis. These conditions may contribute to impaired mobility and decreased cognition. They may also affect the neurological process of inhibiting micturition, resulting in OAB and UI.¹⁵
       Diabetes. This condition is diagnosed in more than 25% of facility residents.⁸ Poorly controlled diabetes (ie, blood sugar frequently over 200mg/dl) may contribute to UI by causing osmotic diuresis. Tighter control of diabetes may improve OAB symptoms. Diabetic autonomic neuropathy can also impair detrusor muscle contraction, thereby exacerbating OAB and UI.¹⁴
       Congestive heart failure (CHF). This condition, which is more prevalent with age, leads to increased fluid volume. Diuretics, the standard treatment for CHF, can lead to OAB as the kidneys excrete excess fluid.¹⁶
       Vaginal atrophy. Nearly all female residents in long-term care have vaginal atrophy. Any associated atrophic vaginitis with inflammation, mucosal erythema, epithelial friability, and tenderness may contribute to urinary symptoms, including frequency, urgency, dysuria, and incontinence.¹⁰
       Benign prostatic hyperplasia (BPH). This condition is common in older males and can lead to symptoms of OAB in addition to obstructive symptoms.¹⁵ While typical management includes treatment to shrink the prostate or relax the urethral sphincter (ie, alpha-blockers), affected patients may still require specific treatment of their OAB symptoms.
       Urinary tract infections (UTIs). These are common, affecting 10% of long-term care residents each month.⁸ Acute cystitis can exacerbate OAB symptoms. Although asymptomatic bacteriuria does not warrant antibiotic treatment, a UTI in a resident with new onset or worsening OAB symptoms should be treated.¹⁷

Medications Contributing to Urinary Incontinence

       An undesirable effect of a medication at the usual doses used to treat a condition is called an adverse drug event (ADE) or adverse drug reaction (ADR).

Table 2

Medications that interfere with the normal neurotransmitter-activated process of voiding and diuretics that increase urine volume may both contribute to UI. Generally, drug-induced incontinence, considered an ADE, is undesirable (see Table 2 for a list of common medications used in long-term care residents and their effects on bladder control). Adverse drug events in facility residents may lead to noncompliance with federal regulations. Federal Tag 329 (Tag F329), the “Unnecessary Drug” regulation, states that a long-term care resident has the right to be free from unnecessary drugs. In order to be considered a “necessary” drug and reduce the risk of getting a deficiency, the medication must have a “supporting diagnosis or reason” listed in the medical record, be adequately monitored, be given at an age-appropriate dose and for an appropriate duration, not be involved in duplicative therapy, and be “free of significant side effects or adverse drug reactions (ADR).” If a medication fails to meet any of these conditions, the prescriber must document that the benefit of continuing the medication outweighs the risk.

Treating Urinary Incontinence

       A healthcare practitioner prescribing for an elder patient should consider a medication’s efficacy in the elderly. However, long-term care pharmacy providers consider efficacy in the elderly the primary determinant of inclusion on drug formularies. In OAB, efficacy is measured as a reduction in urgency, frequency, and UI episodes. While reducing urgency and frequency is important for patients of all ages to reduce fall risk and improve quality of life, reducing UI episodes is the primary measure of efficacy for the long-term care resident. However, when treatment options have similar efficacy, side-effect profiles and the likelihood of drug interactions are often the next most important considerations for formulary inclusion. All of the medications currently available to treat UI are similarly effective. Therefore, it is prudent to focus on selecting the safest choice available.

Conclusion

       Symptoms of UI can often be improved in the frail long-term care resident with proper evaluation and treatment. In the frail elderly population, however, treatment options should be evaluated as much for safety as for efficacy. Ease of medication administration is also important to ensure timely and accurate medication administration. Coupling nonpharmacologic interventions, such as bladder training and/or toileting programs (where appropriate), with proper pharmaceutical care may offer the best option for reducing the complications of OAB. Helping healthcare providers to differentiate between the types and causes of UI and select the best treatments can help both the residents and staff of long-term care facilities.