Pathophysiology of urinary incontinence

Numerous physical disorders contribute to the pathogenesis of UI among nursing home residents. Urologic, gynecologic, and neurologic disorders, and functional impairments, particularly dementia and lack of mobility (including bed restraints), are primary factors. Many cross-sectional studies have demonstrated that UI and FI are associated with urinary tract infections, respiratory infections, constipation, and other disorders. Recent studies suggest, however, that reducing UI and FI alone does not improve skin health or reduce hospitalizations or decrease urinary tract infections. Multifaceted interventions may be necessary to improve the chronic health problems associated with both forms of incontinence among nursing home residents.

It is important to diagnose and treat the underlying disorders, especially reversible conditions, to reduce the severity and frequency of incontinence episodes. Even when physiologic conditions are improved, however, nursing home residents may continue to have “functional” incontinence for several primary reasons: (1) lack of mental awareness; (2) physical inability to properly toilet themselves; (3) failure of understaffed nursing homes to provide residents with frequent assistance in toileting (prompted voiding); and (4) tendency by staff to rely heavily on special undergarments and absorbent pads. This article reviews the risk factors for the development of UI and FI and addresses how nursing homes can reduce incontinence by providing residents with adequate toileting assistance in the face of staff and funding limitations.

Medical documentation about the daily care delivery may be so erroneous that even the best-intentioned efforts to improve the care received by residents may not be successful. A culture of inaccurate documentation is largely created by a discrepancy between expectations for health care placed on nursing homes by regulatory guidelines and inadequate reimbursement and staffing to fulfill these expectations. Nursing home staff has little incentive to implement the technologies necessary to audit and ensure data quality if accurate documentation reveals that care consistent with regulatory guidelines is not or cannot be provided because of inadequate staff. A survey process that largely focuses on chart documentation to assess quality provides further incentive for care-process documentation as opposed to care-process delivery.

There are two potential solutions to this problem. The first solution is to maximize the efficiency of available staff resources by targeting residents for toileting programs who are most responsive. This at least makes it more feasible for staff to provide adequate toileting assistance to a subset of residents and in so doing increases the probability of accurate documentation. Validated methods to accomplish such targeting are described later in this article. The second solution is to implement quality monitoring programs that collect information for improvement purposes as opposed to for compliance purposes. This information could be stored out of the medical record and hence protected from survey scrutiny, which reduces another source of motivation for inaccurate documentation. Methods to collect accurate data about care and the type of data that are useful for improvement have been described.

Urinary incontinence among nursing home residents

Immobility and dementia are the most critical factors contributing to the development of UI in nursing home residents. In three clinical trials assessing the prevalence of UI, 60% to 90% of incontinent nursing home residents had significant mobility problems and the average Mini-Mental Status Score for incontinent residents ranged from 8 to 14, indicating severe cognitive impairment. These data support the conclusions of other research identifying immobility and dementia as the primary risk factors for developing UI.

Immobility increases the likelihood of incontinence among nursing home residents by preventing them from getting to the toilet; dementia reduces their motivation to do so. There is also ample evidence of dysfunction in the lower urinary tract among nursing home residents. Any intervention in the nursing home setting, however, must consider immobility and dementia as first-stage treatment priorities. Treating the bladder abnormalities alone will not alleviate UI especially if the resident lacks consistent access to and motivation to use a toilet.

The degree to which both immobility and dementia contribute to UI is best estimated by clinical trials using prompted voiding. Three intervention elements of a prompted voiding program compensate for immobility and dementia-associated risk factors: (1) residents are approached every 2 hours and asked if they are wet or dry; (2) residents are prompted up to three times to request assistance; and (3) when they ask for assistance, residents are socially reinforced and given that assistance to the toilet. This simple intervention is labor intensive, does not involve treatment of lower urinary tract abnormalities, and is effective. In various clinical trials, 33% to 60% of residents reduced the frequency of their incontinence to less than one episode per day or became continent after participating in a prompted voiding program.

Urinary incontinence among nursing home residents

Immobility and dementia are the most critical factors contributing to the development of UI in nursing home residents. In three clinical trials assessing the prevalence of UI, 60% to 90% of incontinent nursing home residents had significant mobility problems and the average Mini-Mental Status Score for incontinent residents ranged from 8 to 14, indicating severe cognitive impairment. These data support the conclusions of other research identifying immobility and dementia as the primary risk factors for developing UI.

Immobility increases the likelihood of incontinence among nursing home residents by preventing them from getting to the toilet; dementia reduces their motivation to do so. There is also ample evidence of dysfunction in the lower urinary tract among nursing home residents. Any intervention in the nursing home setting, however, must consider immobility and dementia as first-stage treatment priorities. Treating the bladder abnormalities alone will not alleviate UI especially if the resident lacks consistent access to and motivation to use a toilet.

The degree to which both immobility and dementia contribute to UI is best estimated by clinical trials using prompted voiding. Three intervention elements of a prompted voiding program compensate for immobility and dementia-associated risk factors: (1) residents are approached every 2 hours and asked if they are wet or dry; (2) residents are prompted up to three times to request assistance; and (3) when they ask for assistance, residents are socially reinforced and given that assistance to the toilet. This simple intervention is labor intensive, does not involve treatment of lower urinary tract abnormalities, and is effective. In various clinical trials, 33% to 60% of residents reduced the frequency of their incontinence to less than one episode per day or became continent after participating in a prompted voiding program.

Treatment options for urinary incontinence among nursing home residents

Bladder abnormalities that are common among incontinent nursing home residents could be targeted for treatment. Residents who are unresponsive to prompted voiding have higher baseline voiding frequencies, smaller bladder capacities, and higher postvoiding residuals. Although lower urinary tract disorders no doubt limit the effectiveness of scheduled toileting interventions, these problems have not been predictive of residents’ responsiveness to toileting assistance.

The best predictor of responsiveness to prompted voiding has been a residents’ ability to toilet appropriately during the first 2 to 3 days of the intervention. Residents who were appropriately toileted (defined as the number of continent voids divided by continent plus incontinent voids) 65% of the time or more during a 3-day trial period tended to maintain continence with a toileting program over longer time periods.

This targeting protocol should result in the identification of 30% to 50% of residents who are most responsive to prompted voiding and it becomes more feasible for staff to maintain consistent toileting assistance with this limited number of responsive residents. The remaining residents are best managed with a less labor-intensive changing program and the use of absorbent pads and diapers unless the reasons for their unresponsiveness to toileting assistance can be addressed.

The most common types of incontinence that may explain a resident’s unresponsiveness to toileting assistance and how these conditions are treated are listed in Table 1 . It is important to note, however, that most of the treatments listed in Table 1 have been evaluated only in community-dwelling incontinent people who were included in the treatment trials because they were independently mobile and cognitively intact. Most long-term-stay nursing home residents do not meet these inclusion criteria.

The most typical types of incontinence documented in the nursing home are stress and urge, with many residents showing symptoms of both. Stress incontinence is characterized by loss of urine because of increase in abdominal pressure (eg, a cough). This condition is associated with pelvic floor or urethral weakness and treatments include surgery (bladder neck suspension) and exercises, such as Kegle exercise or biofeedback. The focus of biofeedback is to teach the patient how to tighten pelvic floor muscles without increasing abdominal pressure. There are published studies showing the effectiveness of these treatments in populations outside the nursing home.

Urge incontinence is characterized by involuntary loss of urine because of detrusor hyperactivity and inability to delay voiding. Medications with anticholinergic effects and behavioral treatments, such as bladder drills, are recommended treatments. One recent placebo-controlled trial in which oxybutynin was added to prompted voiding showed that a small subgroup of residents with detrusor hyperactivity may benefit from this drug. There are no other controlled trials showing the benefits of bladder relaxant drugs in the nursing home even though new long-acting preparations await controlled testing. Bladder drills require a patient to resist the sensation of urgency to postpone voiding according to a timetable that is progressively increased. Initially the goal is set at 2 to 3 hours and then extended. This procedure has never been evaluated in a nursing home population and it is doubtful if many residents could comply with the therapeutic instructions to delay voiding.

A smaller percentage of nursing home residents have incontinence associated with incomplete bladder emptying that is characterized by high (>200 mL) postvoid residuals. Treatment is suggested if these high residuals are associated with complications, such as recurrent urinary tract infections. Interventions include correcting anatomic problems, such as an enlarged prostate or a large cystocele. If there is no anatomic problem, then either intermittent or indwelling catheters are options.

The interventions for incontinence described in this section are either invasive or require a person to follow multiple-step instructions in the case of the behavioral treatments. It is doubtful if most are widely applicable to a nursing home population and there is evidence that consumers prefer behavioral treatments over the more invasive interventions and medications.

In this regard, it has been suggested that prompted voiding be a first-line treatment for incontinence for all nursing home residents and that further treatment only be considered for those residents who are highly motivated to be continent but who remain frequently wet in response to prompted voiding. The choice of the intervention for this latter group of residents largely depends on their ability to follow multistep instructions or to tolerate surgery. In addition, if the resident is unable to toilet independently then any treatment has to be supplemented with prompted voiding.

Fecal incontinence among nursing home residents

In nursing homes, FI may be a marker of declining health and increased mortality. In one study, 20% of nursing home residents developed new-onset of FI during a 10-month period after admission. Also, long-lasting incontinence was associated with reduced survival. Immobility and dementia preclude residents from getting to the toilet in time and are important risk factors for the development of FI. Adjusting for the major reasons to apply patient restraint (dementia, blindness, arthritis, and stroke), along with other risk factors for incontinence, the use of patient restraints was the most significant cause for the development of incontinence in nursing homes in one recent report.

Two studies that did not involve a toileting program have confirmed that dementia and immobility play a key role in the development of FI. A retrospective study found that 46% of 388 nursing home residents were affected by FI. Although diarrhea was the strongest risk factor, dementia actually played a greater role in the development of FI. Borrie and Davidson also found that 46% of subjects (among 457 long-term care hospital patients) had FI, and concluded that immobility and impaired mental function were independent predictors of FI. Immobility was the strongest predictor of FI as measured by nursing time spent toward assisting incontinent patients, handling laundry, and incontinence supplies.

The role of these risk factors can be minimized by a prompted voiding program, even if residents have disorders that contribute to their FI. Two studies have estimated the effectiveness of scheduled toileting programs in reducing the frequency of FI, thereby assessing the extent to which immobility and dementia contribute to this condition. In one study, toileting assistance for UI offered to male and female residents every 2 hours significantly decreased UI and significantly increased the number of appropriate bowel movements from 23% to 60% (n = 165). Although the frequency of FI was not decreased significantly, there was a trend in this direction. The second UI treatment trial involved a comprehensive intervention that integrated toileting assistance (prompted voiding), a fluid-prompting protocol, and exercises to improve mobility. Residents showed significantly decreased UI, increased fluid intake, and improvements in mobility endurance. This program also resulted in a significant decrease in the frequency of FI from 0.6 to 0.3 episodes per day and a significant increase in appropriate fecal voiding in the toilet. The frequency of FI was only measured over 2 days, however, and 46% of the residents had no fecal voids (continent or incontinent) revealing that constipation remained a persistent problem. The lack of a significant difference between the intervention and control groups in the total frequency of fecal voids during this 2-day monitoring period suggested that constipation was not alleviated by the intervention. Neither of these trials controlled for laxative use, medications with constipating side effects, or caloric intake, which was known to be very low; consequently, fiber intake may have also been low. Also, anorectal function was not determined.

Similar to UI, several gastrointestinal disorders can play a role in the etiology of FI in nursing home residents. Common causes are impaired anorectal sensation, lower sphincter squeeze pressures, and reduced integrity of sphincter or pelvic floor muscles. One report described a subset of mentally intact but immobile nursing home residents, particularly stroke victims, who have FI but have normal anorectal function. These residents require assisted toileting more than any other interventions. This small study compared anorectal measurements for four nursing home residents who had FI; six ambulatory, elderly community-dwelling subjects who had FI; and four controls without FI. Two of the four nursing home residents had normal measurements on anorectal testing, with normal squeeze duration and squeeze pressures. Despite having intact mental status and an awareness of impending bowel movement, both individuals had stroke-related impairment of their mobility and required toileting assistance. The other two nursing home subjects, however, had reduced squeeze pressures and other abnormalities compared with controls. The results suggest that although symptoms normally correlate with manometric abnormalities in ambulatory persons with FI, such correlation may not exist among immobile nursing home residents with FI. An incorrect diagnosis of the factors influencing FI may have a negative effect on the perception of nursing home residents regarding their management, and may partially account for the disparity between their observed symptoms and anorectal measurements.

Constipation plays an integral role in the development of fecal impaction and FI among the institutionalized elderly. The incidence of constipation increases with age and is also attributable to immobility, “weak straining ability,” the use of constipating drugs, and neurologic disorders. Defined as two or fewer bowel movements per week, hard stools, straining at defecation, or incomplete evacuation, constipation can result from a combination of lack of dietary fiber intake, poor fluid intake and dehydration, and the concurrent use of various “constipating” medications. Fecal impaction, a leading cause of FI in the institutionalized elderly, results largely from the person’s inability to sense and respond to the presence of stool in the rectum. Decreased mobility and lowered sensory perception are common causes. A retrospective screening of 245 permanently hospitalized geriatric patients revealed that fecal impaction (55%) and laxatives (20%) were the most common causes of diarrhea and that immobility and FI were strongly associated with fecal impaction and diarrhea.

Constipation, fecal impaction, and overflow FI are common events in nursing home residents. Until recently, in the absence of comprehensive anorectal testing, drug-induced constipation was considered the most likely explanation. The high prevalence of constipation in nursing home residents, however, is only partly caused by adverse drug effects. A recent study reported systematic anorectal testing of nursing home residents with FI. This preliminary report documented for the first time impaired sphincter function (risk factor for FI), decreased rectal sensation, and sphincter dyssynergia (risk factor for constipation and impaction) affecting up to 75% of the assessed residents. The sphincter dyssynergia documented in these nursing home residents with FI has shed new light on the frequent association between constipation and FI in nursing home residents.