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A recent study from the USA has revealed that more than half the people aged 65 or more who live outside nursing homes report episodes of bladder or bowel incontinence, with women experiencing the condition considerably more than men.
12% of women who suffer from urinary incontinence had severe or very severe forms of the condition, while the rest of the women and virtually all the men surveyed reported slight or moderate incontinence according to the study, released by the National Center for Health Statistics, an American government organisation. The study is the first U.S. study to pull together data on incontinence among people living in their own homes, nursing homes, and in residential care facilities and in hospices, as well as people who receive health assistance in their homes. In the past, because different definitions of incontinence were used for the various groups, the researchers had been unable to directly compare the results for one group against each other.
“The purpose was to show…the prevalence and the magnitude of the issue,” said Yelena Gorina, of the agency’s Office of Analysis and Epidemiology. “Because it’s a very serious issue, a very debilitating issue.”
Benjamin Brucker, an assistant professor of urology at the NYU Langone Medical Center in Manhattan, said that he hoped that a major study that shows how common incontinence is will encourage people to overcome the shame and embarrassment of the condition. “A lot of people that…have incontinence are afraid or fearful or not willing to bring it up to their doctor, and not willing to bring it up to their family members,” Brucker said.
Results varied considerably for people in institutions, from the 39% in residential care facilities who reported an episode of bladder or bowel incontinence during the seven days before they were interviewed to the 75.8% of long-term nursing home residents who could not completely control bladder or bowel function in the 14 days prior to their survey.
As with many other countries, incontinence has become more prevalent in the U.S.A. as the population has aged.
Technology is becoming increasingly common in homecare to enable people to live independently but it is still very much a rarity in care homes, yet monitoring people through technology can enable people in care homes to be more independent, keep them safe and allow staff to give more individualised care.
St Cecilia’s Care Home in Scarborough was one of the first care homes in the UK to install monitoring equipment to check for incontinence and falls.
St Cecilia’s, in partnership with North Yorkshire County Council, introduced a range of monitoring equipment in June 2009, this included 18 enuresis sensors, a chair occupancy sensor, two falls detectors, three door exit sensors and a nursecall overlay.
The home cares for people suffering from mild to severe cases of dementia and the equipment gives quick and timely alerts to incontinence and residents out of bed or outdoors.
In recognition of its pioneering work, the care home has just been shortlisted for an Innovation Nation award and was recently visited by the Department of Health.
“We were approached by North Yorkshire County Council to trial the equipment and we thought it would help to give people with dementia more independence and choice,” says Mike Padgham, owner of the home.
He has found it has helped the home give the residents better care. “Each resident has an assessment so we can determine what equipment they need. We can monitor if they have a fall or if they go out of their bedroom and there are urinary sensors so we don’t need to keep checking if they need changing. Previously staff would have had to make regular ‘just in case’ checks on people suffering incontinence, which was intrusive for the residents.
“It has also given them more independence as they can go outside when they want to now as, if they fall in the garden out of sight, the sensor which can be worn as a wrist watch will go off. It allows them to be safe and also be independent. Their relatives are very pleased with it. Initially staff were worried that we were going to reduce staff levels or use the technology to watch them but it has given them more time to spend on one to one care. It has even enabled us to accept residents with higher care needs,” he says.
The equipment was trialled from June 2009 to August 2010 at St Cecilia’s care home and its success means it is still being used every day in the home.
1. Establish a culture that promotes continence, rather than just checking and changing incontinence products. This includes establishing teams of incontinence specialists, setting incident-reduction goals, raising awareness of a plan, periodically ensuring guideline compliance, benchmarking and establishing a staff competency program.
2. Develop a formal bowel and bladder programme. One of the best ways to decrease the incidence of incontinence in long-term care residents is having a clear bowel and bladder program that is in compliance with current clinical guidelines (e.g. NICE). Often suppliers of incontinence pads can supply such a programme.
3. Promote continence with broad staff education and training. Low incontinence incidents and positive survey results may lull many providers into a false sense of security, sometimes surveyors may overlook how the home is promoting continence and you might continue the same process that has contributed to higher incidents of falls, nosocomial infection or depression. Proper staff education and support on perineal care is essential to help eliminate skin breakdown or redness before it can occur as well.
4. Properly assess and identify vulnerable areas. Proper assessments include identifying the type of incontinence, and often the cause. The assessment should lead to the proper care plan and also the type of incontinence product and care that will best support the highest possible level of continence for each individual. A structured program can help identify and treat some very simple underlying causes of incontinence, such as medications, poor dexterity or mobility, anatomical defects or lack of appropriate staff.
5. Keep your eyes and ears open. It might seem simplistic, but many homes link cost with effectiveness when often a more expensive treatment or product will be more effective and reduce overall costs through such areas as reduced treatment of skincare issues or laundry bills. There are undoubtedly many treatments available for incontinence, but the best treatment is simply to pay vigilance and attention to each individual clients situation.
6. Be mindful of the total cost of incontinence. Incontinence pads represent only a fraction of care costs. Consider other metrics such as change rates, cost of laundry, nursing time, medications or ointments, falls and cost of skin injuries.
7. Understand that it’s more than just a physical problem. Preserving the dignity of the resident is paramount. Staff can help residents emotionally by making them feel confident, and by providing quality support products that reduce the incidence of embarrassing leakage.
8. Provide easily identifiable products. Make it as easy as possible for staff to identify the proper supplies, including undergarments and topical treatments, e.g. through using products where the packaging means that names can be read from across the room and also colour-coded packs and products. Staff can are often be overworked, so different products can be quickly identified can help when staff are busy.
Some Mistakes to avoid are:
– Using outdated continence management policies or guidelines.
– Assuming a good survey and few incontinence incidents mean you are managing the problem well.
– Skipping an initial assessment of vulnerable areas of the body.
Does Alzheimer’s disease lead to incontinence? Not necessarily, asserts a University of Virginia researcher in the USA. A new grant from the National Institutes of Health will help professor Karen Rose determine whether people living with Alzheimer’s are incontinent because of the disease, or whether their incontinence and night time agitation – common symptoms of the progressive brain disease – are connected and might be, therefore, better and more thoughtfully managed.
“People assume that incontinence is part of the disease, that ‘that’s the way it goes,’ but that may not be, in fact, true,” said Rose, who will lead the two-year study. “The answer isn’t necessarily just putting a diaper on someone.”
Between 70 percent and 90 percent of those living with Alzheimer’s are cared for by family members in their homes, and many who are treated for agitation – another common occurrence among this population – are given sedating medication which may have an effect on their continence. Roughly 53 percent of Alzheimer’s patients suffer from incontinence, Rose said.
One in eight people 65 and older, are living with the degenerative brain disease, which robs victims of memory, cognitive function and physical control.
Urinary incontinence, common in Alzheimer’s patients, often means families feel cornered into sending their loved ones into a nursing home. The study’s goal, Rose said, is to offer solutions to families caring for their loved ones.
“It’s very intimate, very personal, these things,” Rose said, “and it can be a tipping point for institutionalization.”
Rose, along with colleagues and professors John Stankovic and John Lach, and collaborator Janet Specht from the University of Iowa, will study a group of 50 local individuals with Alzheimer’s who are at least 65 years old who receive care at U.Va.’s Memory and Aging Care Clinic. Those with Alzheimer’s will wear a wrist actigraph at night – a device created by Lach and Stankovic that measures physical movement and agitation – and will sleep on beds with wetness sensors. They will also be recorded for verbal agitation between the night time hours of 9 p.m. and 7 a.m. Data will be collected over five days and nights, and tabulated to see whether physical and verbal agitation precedes bed-wetting and whether there are timing issues to consider – whether a person is incontinent early in the evening or in the morning, for example – that might help families better keep ahead of the problem.
Rose said the study could ultimately inform the way families manage incontinence by offering a template for home study of Alzheimer’s patients and their continence patterns. She said her study will bring a difficult topic better into the light.
“There’s a stigma attached to all of this – the disease, the incontinence, the burden on families,” Rose said. “But we still don’t know whether some very basic things are linked. We don’t know that urinary incontinence is just part of the disease. Are they agitated because they’re incontinent? Are there things we can do to relieve that?”
Rose, an associate professor of nursing and director of the Bachelor of Science in Nursing program, has taught acute and specialty care courses at the school since 2006.
Issues around urinary incontinence are challenging for nursing home staff members who provide physical and emotional care to residents. The rate of urinary incontinence is estimated at between 45% and 70% for residents in long-term care (LTC) settings.
A knowledge gap exists among nursing home staff members in the areas of attitude toward Urinary Incontinence, as well as different types, causes and assessment of Urinary Incontinence. To reduce the existing knowledge gap, an interdisciplinary research team from the University of Southern Indiana created an innovative education program titled “Bladder Buzz” staff.
The purpose of the Bladder Buzz program is to dispel myths about Urinary Incontinence, improve knowledge about the different types, and to begin to build assessments skills among care home staff. Bladder Buzz is a seven-week program designed for long-term care setting staff members who provide emotional and physical support to residents.
The Bladder Buzz program begins with an emotive case study that discusses emotional and physiological issues related to incontinence that residents may encounter when they move into a care setting. The emotive case study is a fictional story, but it is built on direct responses that residents have provided to the research team in a previous research project (indicated in italics below). The elder featured in the case study is named Mrs. Kingsley. In the case study, Mrs. Kingsley does not want to ask too many questions of the staff on her first night in the care setting. Mrs. Kingsley wanted to talk about her continence issues, but the staff seemed rushed. When alone in her room, Mrs. Kingsley cried softly. A series of case study questions are posed to staff members in small groups and are intended to become more complex as the case study evolves. Examples of case study questions include:
1) How do you handle urinary incontinence with new residents who move into your care setting?
2) How can you improve dialog with residents on the topic of urinary incontinence?
3) Based on what you know from the story, what types of incontinence could Mrs. Kingley have?
4) What type of toileting program could you suggest in order to help Mrs. Kingsley?
5) How would a toileting program impact Mrs. Kingsley quality of life?
6) How would a toileting program for Mrs. Kingsley impact your quality of life as a caregiver?
After the first session in week one, evidence-based educational handouts related to Incontinence are distributed to staff over the next six weeks. A mnemonic, dubbed SUMO Fun, was developed in order to aid staff memory on the different types of Urinary Incontinence. Finally, as the culminating session, an evidenced-based Bladder Buzz Jeopardy game was developed to engage staff and promote learning in a fun and interactive manner. The Bladder Buzz Jeopardy game categories include: types of Incontinence, bladder dysfunction, case scenarios, and treatment.
The Bladder Buzz program has been tested in six Midwest nursing homes and preliminary results indicate significantly improved knowledge about Urinary Incontinence among nursing home staff. Providing nursing home administrators and staff educators with tools to improve knowledge about Urinary Incontinence can potentially reduce the number of episodes residents experience, improve residents’ health related quality of life, and improve nursing home quality. To access Bladder Buzz material for your staff, visit http://health.usi.edu/CHAW/bbabout.asp