A Nursing Analysis of the Causes of and Approaches for Urinary Incontinence Among Elderly Women in Nursing Homes (PART 1)
Quantification of the Problem
Urinary incontinence. To those who suffer from, live with, and care for others experiencing the condition, the meaning is clear.
Ouslander and Johnson1 define urinary incontinence (UI) as the involuntary loss of urine in sufficient amounts with enough frequency to have negative health and social consequences. Miller2 acknowledges that UI is widespread, but has been largely ignored for years. In an older article, Borrie3 concludes that incontinence is often viewed as inevitable and accepted with resignation. Since then, the release of the AHCPR (Agency for Health Care Policy and Research, now called the AHRQ - Agency for Healthcare Regulation) Clinical Practice Guidelines in 1992,4 and again in 19965 has had the desired impact: a wealth of research information on UI is now available. Advances in the care of community-based women with UI have been significant. Many are seeking help with treatable forms of incontinence and benefiting from the newest technological advances: hormone replacement therapy, electrical stimulation, exercise, vaginal cones, medications, and behavioral approaches.
The situation for incontinent elderly women residing in nursing homes, however, remains largely unchanged. Despite numerous research studies performed within nursing homes, few have been able to demonstrate lasting change in the care of and enduring outcomes in this population. In her recent review of incontinence in long-term care, Prochodo6 notes, "Despite its prevalence (in long-term care), there is a lack of knowledge and understanding about urinary incontinence, its causes, and its treatment."
The need for information is great and growing, as are the costs. Urinary incontinence has been reported to be one of the leading causes of nursing home admission.7 Borrie3 reports a UI prevalence of 62% in one nursing home in Canada, which increases to 80% when residents who remain dry due to staff toileting frequency are also included in the count. In general, studies indicate that prevalence in women is twice that in men in nursing homes and greater than that in the community.8 Although statistics by sex are not available, classic estimates from the AHCPR place prevalence at approximately 50% and it is assumed to be higher within the nursing home. Elbadawi, Yalla, and Resnick9 state that 82% of all incontinent institutionalized elderly are women, and that 60% of these women have an overactive detrusor, one cause of UI.
The costs are staggering. Figures that include a $8.6 billion Medicare B cost in 1995 highlight the importance of this issue.10 The most recent figures, reported by Wagner and Hu,11 estimate the 1995 societal cost of incontinence to be $26.3 billion (for incontinence care in all settings) or $3, 656 per individual with incontinence. They further detail that most of the costs (97%) are direct costs - ie, resources used to treat UI and to mitigate its effects. Given that UI remains underreported, the true costs of UI may be higher than predicted.
Recent evidence suggests palliative rather than rehabilitative services predominate. Future research needs to integrate costs, quality of life, and changes in the healthcare delivery system for individuals with UI.11 General consensus is that current approaches are not meeting the continence needs of institutionalized frail elderly.
The literature on UI is vast and often conflicting. Interpretation is complicated by the multiple ways incontinence is defined and classified in the literature. Research is needed on models that could help nurses incorporate continence care for frail elders.12 Palmer, a long-time advocate for improved continence care states, "It is time to pay attention to the total human being and realize that more than a bladder is involved in the experience of an incontinent person."13 Nursing is a holistic science; therefore, the answers to holistic issues may be within the nursing profession. This manuscript focuses on this specific point: utilizing a nursing as opposed to medical framework for the analysis of factors and care.
Limitations of Using Current Incontinence Classifications in the Nursing Home Setting
As new definitions of incontinence are introduced and classification systems refined, the confusion among nursing home staff continues to grow, making the problem more difficult to quantify.
In the latest edition of her classic textbook on urinary and fecal incontinence, Doughty14 explains that the development of standard classification and terminology in the field of continence care has been complicated by the fact that continence does not belong to any one specialty and the natural tendency of each involved specialty is to use its own "system" and vocabulary. The International Continence Society (ICS) established a standard terminology, used since 1973, for lower tract dysfunction based on functioning of the bladder and sphincter. Initially a simple system, the current revision includes symptoms and conditions and revised terminology.15 The revised ICS system is still the one most widely used by clinicians. The North American Nursing Diagnosis Association (NANDA) has patterned its classifications after the current ICS system; the AHCPR Guidelines are similarly based.14 Many of the diagnoses require complete urodynamic study results. Although this standardization has been helpful in establishing a consistent physiologic framework and assessment of the specific dysfunctions that direct management of care, limitations in applying this system to address incontinence caused by conditions other than filling and emptying problems still exist. Incontinence problems such as difficulty in gaining access to a toilet due to decreased mobility or knowing when and how to use a toilet due to cognitive decline are common issues for nursing home residents. These two different problems, with different solutions, often share the classification functional incontinence. In addition, UI is often designated as either transient (acute) or established (chronic).
As definitions of the various types of incontinence increase in accuracy and specificity, their relevance to the nursing home setting may actually decrease, as access to the testing necessary to diagnose and treat at that level of sophistication may not be available or appropriate. In addition, new research is blurring the lines among what once were seen as distinctly different types of incontinence.
Other classification systems address levels of incontinence. Fonda12 classifies UI types by patient characteristics, including related symptoms and level of help needed, as independent continence, social continence, dependent continence, and partial continence. Miller2 classifies UI by characteristics (eg, leak frequency and voiding schedule) into five classes ranging from "very mild" to "very severe." These classifications may prove significant in the nursing home setting.
The Basic Ingredients for Continence
A summary provided by the National Institute for Nursing Research defines UI as, "a complex disorder arising from physical, psychological, social and environmental factors. Micturition and continence are complex functions requiring central and peripheral nerve system coordination. Although there is a basic understanding of this function, there are still significant areas of disagreement."16 Gray and Burns observe, "The principle mechanisms maintaining urinary continence are anatomic integrity of the lower urinary tract, neurological control of the detrusor muscle by the central and peripheral nervous system, and competence of the urethral sphincter mechanism."17 These authors also note that in addition to the integrity of the urinary tract, cerebral and environmental components are required for continence to be maintained: "The person must also recognize cues to urinate, must move to reach the toilet and must manipulate clothing in preparation for urination." The absence of any of the above ingredients may initiate the cascade leading to incontinence.
Is it Temporary or Permanent?
Generally, two types of urinary incontinence are recognized: transient (acute) and established (chronic), but a recent study by Nygaard and Lemke18 demonstrated that in some older women, UI is a dynamic state, with women moving back and forth along a continuum between continence and incontinence - approximately one-tenth of women are no longer incontinent when interviewed 1 year later. They also found that older women are highly likely to remain continent if they are continent at the beginning of old age, especially if they remain mobile.
Transient incontinence is caused by reversible stressors such as fecal impaction, urinary tract infection, delirium, atrophic vaginitis, or the side effects of many drugs. Established incontinence is generally categorized into four types: stress, instability (including urge and reflex), functional, and extra-urethral. Overflow incontinence may represent another form of established incontinence if due to a chronic problem, or it may be transient if due to a reversible problem, such as impaction. The boundaries between what may be considered a transient type of incontinence and an established type are not always evident. For example, stress incontinence may be considered a chronic form of incontinence. However, if it is due to atrophic vaginitis (ie, dryness of the urethral tissues, which leads to loss of coaptation), as opposed to the hopelessly stretched pelvic floor of a woman who experienced traumatic childbirth, it may be reversible once estrogen cream is initiated. In an intensive study involving bladder biopsies and urodynamic studies of elderly subjects, Elbadawi, Yalla, and Resnick9 found that although the biopsy and urodynamic results matched, demonstrating the presence or absence of pathology, no correlation was noted as to the presence or absence of urinary incontinence. In an earlier study by Gilpin et al,19 bladder biopsies demonstrate significant loss of nerve associated with the detrusor muscle between young and old participants, but these findings are not associated with any changes in function.
Additional Factors that Predispose Elderly Women in Nursing Homes to Incontinence
Additional factors may play a role in the development of incontinence, regardless of the type. Diabetes and other chronic illnesses, dehydration, and especially impaired mobility must be considered.10,18 Cognitively intact patients who have mobility or balance problems may not have the ability to suppress the urge to urinate until someone can help toilet them. Residents who, despite their independence, are unable to ambulate or move their wheelchairs to the toilet in time also may experience incontinent episodes.10
The urge to "go" and its connections to age, decreased mobility, falls, and the "brain factor". Researchers are working to discern the secrets of continence in the elderly. Among incontinent elderly people undergoing rehabilitation in institutions, urge incontinence is by far the most common type, both symptomatically and objectively. Urge incontinence gives rise to more severe urine loss than other types and is often troublesome at night; thus, it is characteristic of the severely incontinent older person.20
Urodynamic studies of older people with urge incontinence show striking similarities. As the bladder fills, the detrusor remains inactive until a single, involuntary detrusor contraction develops and leads to involuntary voiding. Often, the person has no sensation of bladder filling until the contraction is about to occur. The abnormality has been named the uninhibited overactive bladder. The causes of this syndrome may be idiopathic or secondary to urethral obstruction or neuropathy. Regarding the elderly, consensus is growing that a dysfunction of brain regions concerned with control of the bladder and urethra occurs. Numerous researchers have identified that two factors, immobility and impaired mental function, predominate in the incidence of geriatric urge incontinence.8,20-23
Tinetti et al24 evaluated the connection of falls and urinary incontinence, two very common geriatric syndromes. Until recently, these two syndromes were thought to result solely from distinct anatomic and/or physiologic abnormalities, but they occur in tandem more often than not. This finding has led to a new approach. It is suggested that the loss of compensatory ability may be an important etiologic mechanism for the development of the geriatric syndromes and functional dependence. Johnson and Gary8 acknowledge that although no history of neurological involvement may be evident, extensive urological testing may show it to be an important factor. Borrie3 questions the dynamic interaction between mobility, impaired mental ability, and urinary incontinence and asks whether immobile patients are incontinent because they tend to be mentally impaired or if immobility is related to incontinence, independent of mental impairment.
Griffiths et al20 looked more closely at the "brain factor" involved in geriatric incontinence. They note that geriatric urge incontinence with reduced sensation is not only associated with cognitive impairment but also with global impairments of cortical perfusion. According to the SPECT scanner, cerebral dysfunction and the cortical center that controls voluntary voiding share the same location, believed to be medial and posterior to the frontal lobes of the cortex. Incontinence and loss of bladder sensation may be the result of lesions in this location. Seidel et al25 used the Dementia Rating Scale (DRS) to validate the relationship between mental function and incontinence in a group of geriatric rehabilitation patients. Evaluations at both admission and discharge from an acute rehabilitation setting revealed a positive correlation between incontinence and increased dementia. Additionally, admission status significantly predicts incontinence status at discharge. A similar finding is reported by Owen, Getz, and Bulla26 from their study of 75 stroke patients to determine risk factors for continence at admission and discharge from hospital. Subjects who remain incontinent at discharge have more cognitive deficits than those who achieve continence.
Stress incontinence and other types. A discussion of factors related to incontinence in elderly women would be incomplete without addressing stress incontinence. Technological advances and greater anatomic study precision have combined to expand understanding of the pelvic floor's role in continence.27 Anatomic structures are different than previously believed; specifically, the neurologically intact levator ani is more aptly described as a horizontal shelf on which pelvic viscera are supported, as opposed to acting as the sling described in anatomy textbooks. Contraction of this muscle provides a force that opposes downward pressure. In addition, in the continent woman, due to smooth muscle autonomic innervation, a rise in intra-urethral pressure precedes increased bladder pressure to maintain continence, suggesting more neurological involvement in stress incontinence than previously believed.
A dynamic interplay exists between stress incontinence and other forms of incontinence. According to Newman and Giovanni,28 poor pelvic floor muscle function aggravates overactive bladder because external urinary sphincter contraction aborts an overactive bladder contraction. This implies that even if overactive bladder syndrome is identified, a logical first step in a continence program may be to treat for stress incontinence.
External Factors Affecting Urinary Incontinence
Equally important to the anatomic and physiological causes of UI are the cultural, psychological, and environmental factors. Robinson29 says little is known concerning what nursing home residents think, feel, and do about UI. In a descriptive study of nursing home residents experiencing urinary incontinence, some residents see UI as an annoying problem, while others describe it as devastating. Ouslander and Abelson30 report that in community-dwelling seniors, self-reported urine loss of larger amounts is associated with more negative perceptions of quality of life. Data from Diokno et al21 suggest that family history may impact incontinence at the genetic, behavioral, and/or cultural level. In addition to a well-known association between depression and incontinence, motivation is identified as a crucial element by some researchers.29,31 The attitudes of staff caring for residents with UI also exert an influence. Borrie3 asserts that the institution's ability to compensate for the disabilities of its residents, determined by nursing philosophy, approach to incontinence, and staffing levels, affects the extent of the expression of physical risk factors as incontinence. Johnson and Gary8 acknowledge that the facility may contribute to UI - specifically, that maintaining continence and the ability to perform certain toileting skills are directly related. Harke and Richgels32 show in their four-site study conducted on new approaches to toileting that incontinence was the norm in all sites.
The Value of Using a Nursing Theory
Incontinence in the nursing home is a multifaceted challenge - one not solved by a single action or decision. In many ways, the newest information available on incontinence in nursing homes reinforces the fact that a new view is desired and required because old models of care are not meeting the need. The availability of new technology for detailed diagnosis tempts healthcare providers to perform more involved testing regarding incontinence. However, money to pursue additional laboratory work and purchase sophisticated machines and expensive drugs is not available in most nursing homes. Perhaps the key is to only provide unlimited technology and medical support to those who can achieve, or are close to achieving, total cure, and to promote the most comfortable adaptation within the environment for others.
Parker33 says the practice of nursing is "lived moment-to-moment, day-to-day, and is guided by values and beliefs and knowledge held by the individual," serving to ground both nursing theories and practice. Brown34 tells nurses that using conceptual models or theories provides them with a broad perspective within which they can view client situations. This perspective helps them organize and make sense of the myriad of information relevant to each case. She further avows that conceptual models can help nurses plan and implement care in a purposeful, proactive, and comprehensive manner, which is enhanced if a natural fit exists between the model and the nature of the clinical issues of the patient population.
The logical next step is to use the guidance of a nursing theorist to direct an investigation of the "problem" of incontinence among elderly women in the nursing home. This framework meshes well with the nursing theory of Sister Callista Roy. The Roy Adaptation Model is based in systems theory. The individual is seen as a bio-psychosocial adaptive system, and nursing is viewed as a humanistic discipline that places emphasis on the person's own coping abilities.
According to Roy, the individual and the environment are sources of stimuli that require modification to promote adaptation. When the demands of the environment are too great, or the person's adaptive mechanisms are too low, the person's behavioral responses are ineffective for coping. Effective adaptive responses promote the integrity of the individual by conserving energy, and promoting the survival, growth, reproduction, and mastery of the human system.35
Nursing Assessment of Incontinence Using the Roy Adaptation Model
Although they are complex and varied, variables used to assess continence should be relevant to that patient.36 Roy37 says that in order to promote adaptation, nurses must assess behavior and stimuli to plan interventions to best manage them. A concept to utilize in the application of this model must include a full assessment of the environment, as the nursing home places unique stressors on its residents. According to Chitty,35 "all conditions, circumstances and influences surrounding and affecting the development of behavior of the individual must be considered."
Assessment of behavior and stimuli. Roy suggests four areas of assessment for behavior in urinary problems that can be applied to UI: 1) amount and character or urine, 2) presence of frequency or urgency, 3) pain or discomfort, and 4) laboratory findings. Assessment of stimuli for UI include assessment of nine areas: 1) the disease, 2) fluid balance, 3) immediate environment, 4) medications, 5) pain and coping, 6) usual elimination patterns, 7) stress, 8) family and culture, and 9) developmental stage. Once a complete assessment has been made, a nursing diagnosis and plan can be conceptualized.
Behavior. Assessing the characteristics of urine is a basic nursing skill that becomes crucial in the care of incontinent residents. The volume and character (ie, color, clarity, and odor of urine) are just the beginning of the assessment. The resident's position during voiding is noted (eg, standing, sitting, squatting) and any postural preferences caused by physical necessity, psychological need, or lack of help. Noticing if the resident requests toileting before voiding or becomes restless is important. Frequency and urgency are evaluated by the use of a bladder diary, a written record of voiding (both continent and incontinent). The clinician should note a hurried approach to the toilet, which might imply urge problems, or a lack of awareness of voiding, which might imply loss of bladder sensation. Additionally, any predisposing factors to involuntary leaking of urine (eg, laughing, coughing) should be documented. The presence or absence of pain or discomfort can signal the nurse to rule out urinary tract infection, a potentially reversible cause of UI, although many times urinary tract infections in the elderly are painless. Laboratory tests and other tests such as urodynamics or post void residuals can help further identify the causative factors. Nurses must be aware of normal lab values for urinalysis and basic blood work, as well as normal parameters for urinary function, such as usual bladder volume and normal 24-hour output. Miller2 presents a series of six questions nurses should ask when assessing incontinence:
1. What causes you to have a leak of urine?
2. How much urine do you leak at that time?
3. When you get the urge to urinate, can you make it to the bathroom without leaking or do you leak before you get there?
4. How often do you have a leak episode?
5. How many times do you have to get up to go to the bathroom or can you sleep through the night without needing to get up?
6. How often do you go to the bathroom during your waking hours?
By using standardized questioning, the nurse may assess incontinent residents' behavior in a comprehensive and systematic way.
Stimuli. Assessing the multiple stimuli that affect urinary incontinence may require additional nursing skills. The presence of disease in nursing home residents is an expected finding. The nurse must be aware of diseases that may be associated with transient UI versus established UI. Differentiating the expected changes associated with aging from signs of disease is not an easy task. Jewell38 outlines the following changes seen in elderly women: altered concentration of central nervous system neurotransmitters, altered nerve conduction, altered management of fluids, bladder hyperactivity (prevalence of uninhibited contractions), impaired bladder contractility, increased likelihood of pelvic organ prolapse, and thinner more friable mucosa due to decreased estrogen.
Fluid balance has great relevance to incontinence. Inadequate fluid intake is a common finding in elderly incontinent adults who attempt to restrict wetness episodes by drinking less. Instead, the highly irritating concentrated urine makes them more prone to incontinence as well as infection. Colling, Owen, and McCreedy39 found that one-third of their sample of nursing home residents were underhydrated. They contend that adequate fluid intake decreases bladder wall irritation caused by concentrated urine; thus, decreasing the number of small voids.
An evaluation of the immediate environment should assess for obstacles to continence. Inadequate lighting, especially at night, and unmarked bathrooms exist in many nursing homes. Obstructed access renders even ambulatory residents helpless in getting to the bathroom on time. Noise levels, disturbed sleep patterns, and restraints also may add to the possibility of incontinence. As part of the immediate environment, nursing home staff, with their particular attitude towards incontinence, have a significant influence on resident willingness to achieve and maintain continence.
Medications may have the most profound influence on incontinence. The nurse must be aware of the side effects of multiple medications commonly taken by the elderly. Gray and Burns17 identified the following drug classifications as potentially aggravating incontinence: sedatives, narcotics, anticholinergics, parasympatholytics, and calcium channel blockers. Diuretics also may heighten the symptoms of urge and stress incontinence. Ghoneim and Hassouno40 assert that changing or stopping medications may improve or "cure" incontinence in many cases.
The nurse also must be aware of the presence of pain and the resident's usual coping methods. The experience of pain may foster incontinence, as the pain of using a bedpan or transferring to the toilet may be more frightening to the resident than wetting herself. Pain must be ruled out as a reason for the lack of motivation to toilet, and if identified, treated. Often, nurses do not realize that conditions such as arthritis are so painful that they limit the resident's choice to move, and the elderly resident may not realize that the pain can be treated. What may appear as early morning incontinence in an otherwise continent individual may be the result of untreated pain each morning.
An analysis of the patient's usual elimination pattern may yield great value in assessing UI. For example, an elderly woman who usually stays up until 11:00 p.m. at home and voids before retiring may experience early morning incontinence in the institutional setting when she is put to bed at 8:00 p.m. Colling et al39 note that the average elderly nursing home resident voids 5.9 times in 24 hours and that the most frequent void times are: 1:00 a.m., 5:00 a.m., 6:00 a.m., 9:00 a.m.,1:00 p.m., 4:00 p.m., 7:00 p.m., 8:00 p.m., and 10:00 p.m. The disruption of normal voiding patterns by use of a Foley catheter during acute illness may have a detrimental effect on continence as well. Gray and Burns17 suggest that catheter removal following acute care episodes in the elderly, optimally at midnight when it does not interfere with sleep, yields a larger initial voided volume and allows retention to be detected when the urologist is available during the next day.
Physical or psychological stress that affects the patient is another stimulus that Roy includes in stimuli to be assessed by the nurse. Physical stress may be caused by an irritant, such as a fecal impaction or a tumor. Psychologically, the resident may be stressed by transient confusion or by the obsessive fear of wetting herself, which might result in her staying in her room or toileting herself hourly.
Although studies on cross-cultural perspectives are scant, some families and cultures seem to believe that UI is a normal part of aging. Also, certain families are more relaxed about bodily functions than others. The family's acceptance or rejection of the incontinence, by verbal and non-verbal cues, also must be noted.
The final part of the stimuli assessment must include an awareness of the developmental stage of the resident. Elderly women in nursing homes will most likely be in the Erickson Late Adult Stage, where they may be grappling with feelings of integrity and despair.41 If the incontinence is severe, the effect on integrity may be profound. Residents will need help coping with all the losses inherent in institutionalization, adjusting to institutional life, and finding a purpose in living. Complete assessment should include not only the resident, but also an evaluation of family support and communication.
Understanding Compensatory Adaptive Responses
As a precedent to developing a nursing diagnosis and a plan of care, the process of compensatory adaptive responses must be understood. People have a way of responding to and changing their environments, both internal and external. Cognator ability can affect any physiologic need, including elimination, and initiate compensatory responses, affecting the way people adapt to achieve their goals.37 For example, in the continent adult, the higher centers of the brain (frontal lobes and pons micturition center) keep the reflex at the level of the spinal cord inhibited to control when and where voiding occurs. If these higher influences are lost, an alternative must be found to compensate for the lost control. One approach might be timed toileting at a rate more frequent than the bladder would empty in order to keep the person dry. Another approach might include containing the leaked moisture in an effective and dignified way. Elderly women who remain in the community often experience stress incontinence, which is quietly, even secretly, "handled" with disposable pads. Many would consider this to be an adequate adaptation. Further intervention is sought only when the problem becomes unmanageable because of the volume of urine lost. Similarly, in the nursing home, some residents deal with urge incontinence by staying in their rooms. This may not be a positive adaptation, however, because the resident is not socializing or building relationships to adapt socially to institutional life. Therefore, some adaptative responses may be beneficial for the resident and some may be detrimental.