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Incontinency: Trying to Control the Uncontrolled

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1- Approximate time required: 60 min. 

Approved for apd, dd homes

Educational Goal:

To provide Adult Foster Care providers with a systematic approach to bladder retention problems.

Educational Objectives:

      1. Provide an overview of the urinary system.

      2. List the different types of incontinency problems

      3. Provide patient assessment tools

      4. Understand the role of AFC providers have in control therapies

Procedure:

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. Register username and email, (username must be the name you want on your CE certificate).  4.  A computer generated password will be sent to you via email. 5. Retrieve and record the password and click on the link provided in email, or click on [Login] of previous screen and enter the required login information.  6. Read “How to take Exam” instructions in side panel, then take exam.  7. Click on [Show Results] when done and follow the instructions that appear.  8. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 *note- Registration is only required once. On subsequent visits you may go straight to login.     

Disclaimer

    The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

Incontinency: Trying to Control the Uncontrolled

 

     What goes thru your mind when you walk into an elderly living space and smell the strong scent of urine? What is your opinion about the home or institution? Does it matter to you that the elderly residents are content and happy? Or does their incontinency make them appear to be discontent and unhappy?  Can your opinions make it past the smell?

     Incontinency is one of the major health concerns in geriatrics.  When it happens, it is a major source of embarrassment for the patient and the caregiver.  It could range from a few drops leaked while coughing to a total loss of control caused by a stroke.  If it becomes a chronic problem it can lead to infections, social ostracization, loss of independence and a source of significant property damage.

     Regardless of the consequences, as we get older the risk of incontinency increases.  The more often it happens the harder it is to overcome its negative consequences.  The loss of bladder control starts a downward spiral, finally leading to a loss of independence.  About half of the admissions to nursing homes are a result of incontinency.  There is a high probability that a portion of those incontinent patients will move into your home instead.

      When the troubled elder moves into your home does the problem just goes away?  No, their major problem is now your major problem.  But how do you provide control when there is a lack of it? Fortunately, the uncontrolled can be controlled. With some skill and ingenuity from the care provider and some cooperation from the doctor and the patient, incontinency and its consequences can be minimized.  Hopefully, by the end of this article you will gain some insights that will help you in your care efforts.

 

Steps to incontinency Control

    Solving any problem is more efficiently achieved if you have a plan.  Every plan has logically laid out steps. I would like to suggest the following steps.

 

The First Step towards control – Education: What is going on?

 

    The first step in incontinency care is to know what actually is going on.  Let’s examine the urinary tract and its functions.

 

Anatomy of the Bladder

 

     The urinary system starts in the kidneys.  Their purpose is to filter out the waste products from the blood.  This creates urine.  Urine travels from the kidney through tubes called ureters.  Each kidney has one.  The urine is stored in a sack called the bladder.  It is surrounded by contraction muscles. To keep the urine from leaking out, a separate set of muscles called a sphincter surround the bladder exit tube. The tube is called the urethra.

 

Physiology- How things work

 

     Under normal conditions the urethral sphincter muscles keep the urine in the bladder until we voluntarily wish to void it.  During the emptying process we relax the sphincter while simultaneously contracting the bladder muscles.  This results in the urine exiting out of the urethra. 

     At rest the bladder is set up to retain urine.  As fluids build up the bladder stretches.  The stretching is sensed by receptors placed in the bladder’s nervous system.  The stretch receptors send a signal to the brain where an involuntary response is triggered.  That response in turn sends a signal back to the bladder muscles to contract or spasm. We interpret this as an urge to urinate. The fuller the bladder fills the greater the strength and frequency of the bladder spasms.  Eventually we will void the bladder whether we want to or not. That is how the bladder works under normal circumstances

 

The Second step towards control – Gaining the Proper Perspective

  

     The second step to incontinency control is to put things into proper perspective.  Many inexperienced care providers start incontinency care by thinking it is a behavioral issue. This attitude leads to a lot of frustration and anger when their efforts naturally fail. The care provider must come to the realization that no one wants to wet themselves.  Incontinency is really caused by something going wrong in the normal flow of bladder events.  Put into this perspective, incontinency is not a behavioral problem, it is a physical one.  Once the physical problem is identified, solutions can be found.  Then, control of incontinency is much easier to achieve.

 

What are the different physical problems that cause Incontinency?   

 

     In a system as complicated as the urinary tract, many things can go haywire.  Different problems lead to different types of control issues. Each issue requires a different approach toward control.  Knowing the signs and symptoms of each can you help identify the type of control issue that you need to focus on.      

 

The four major types of control issues are:

1. Urge incontinency

     The most common type of incontinency is Urge incontinency.  It occurs when bladder contractions overcome the sphincter muscles of the urethra.  The root of the problem always originates from the nervous system.  Urge incontinency can result from defects caused by a stroke or Parkinson disease; over-stimulations caused by irritations to the bladder, such as infections like Urinary Tract Infections (UTIs); or uninhibited contractions of the bladder.  These are spasms that just happen. Urge incontinency is the most common problem in the elderly.

     Its signs and symptoms are frequent, sudden, and intense urges to urinate at any time of the day.

2. Stress incontinency

     Stress incontinency is the second most common form of bladder problems.  It is associated with weakening of the sphincter’s muscles.  It is caused by bladder infections, surgeries in the groin area, muscle relaxers or changes in the urethra after menopause. 

     Its signs and symptoms are leakage do to sudden increases in bladder pressure, such as when sneezing or coughing.  Elderly who suffer from stress incontinency usually stay dry at night. 

3. Overflow incontinency

     Overflow incontinency happens when the bladder empties improperly.  It’s a result of weak bladder contractions and/or an obstruction in the flow of urine and is often seen in elderly men.  Common causes are nerve damage, as seen in long periods of uncontrollable diabetes or strokes, or obstructions that can cause difficulties in urinating, such as enlarged prostates or bladder stones.

     Its signs and symptoms are shown as feeling of incomplete emptying or small volume of urine output.  Loss of urinary control is often seen at night.

4. Functional incontinency

     Functional incontinency is a problem of accessing toilet facilities. The urinary system functions normally, but the patient can’t get to the bathroom on time.  Examples of this in an Elderly Care setting are a wheelchair-bound patient or an Alzheimer patient. 

     Its signs and symptoms are occurrences that are intermittent.  Environmental factors have the greatest impact for these incontinency suffers.

 

The Third Step towards control – Patient assessment: What is causing the problem?

 

     The third step in controlling incontinency is a patient assessment. In order to control the problem you have to know what’s going on.  But here lies the difficulty. Because of the embarrassment patients feel, they are reluctant to talk to their doctor.  There always seems to be a lack of communication on the subject. Adult Foster Care providers can help by gathering the pertinent information that is needed.  Unfortunately, it’s the step that many Adult Foster Care providers take for granted, despite the obvious natural advantage they have in gathering info.

     One of the greatest strengths of Adult Foster Care is that the caregiver  can really get to know their patient because they live with them.  It’s something that nursing homes and assisted living centers will never be able to match.  It’s too bad that some AFC providers waste that advantage by approaching their job as glorified housekeepers, instead of care providers.  A housekeeper would just complain about the extra work and smell involved when a patient keeps wetting themselves. A care provider would try to find out what is causing the issue. Which are you?   

     The goal of any assessment is to gather the right information. This can be accomplished in any number of ways.  Questions could be asked all at once or the info could be gathered by observations, a little bit at a time. While gathering the info it should be remembered that each person is unique and will divulge information differently.  Remember that this is an emotional subject.  You should proceed in a professional, caring manner. 

     To make your assessment efforts more efficient and to help provide the proper documentation, I have provided the following assessment tool. You may make a copy or alter it any way you desire.

_____________________________________________________________________________________________________________________________________________

 

Patient Incontinency Assessment

Care Home’s Name

 

Name:                                                                                                                                                                                                                                                                     Date

 

When did the problem start?

 

How often does it happen?

 

When does the incontinency usually happen?

(night, day, when coughing ,etc…)

 

Do you feel sudden urges to urinate?

 

On a scale of 1-5, how strong are those urges?

 

Do you strain to urinate?

 

Do you feel that you are emptying your bladder completely?

 

Does it sting to urinate?

 

Is the urine dark-colored or can you see blood?

 

How much urine is leaked out with each episode (a few drops, half emptying, full emptying)?

 

How much fluid do you drink daily?

 

Have you had any past conditions or surgeries in the groin area?

 

 

     Be sure to keep a record of this assessment for future use.  This information is well worth the effort.  This information will be very important for you and the doctor.  Getting the assessment into the hands of other health professionals will only make your and their job easier. It will also enhance your reputation in the health community. 

 

The Fourth Step to control – Planning what to do

 

     Adult Foster Care providers usually are not involved with the planning of medical therapies. You have a different part to play in this process. Your role has 3 different aspects.

1. You are the patient’s advocate
2. You are the therapy coordinator between the different medical providers
3. You are a care provider

     All of these are rolled up into one when you are properly taking care of the patient.  The better you do them, the easier your job becomes. Also, your client remains healthier and becomes a longer-term client.

 

 I suggest the following:

1. Bring the problem to the attention of the doctor and/or home health nurse.  Give them a copy of your assessment questions.
2. Ask the doctor to examine the patient to find out what is going on with the loss of bladder control.  The patient might have to be referred to an Urologist.
3. Follow through.  There are many in our society that think that adult diapers are all that is needed and they leave it at that. As a patient advocate, and in your business’ best interest, sometimes you need to push a little.  One way of pushing the doctor without appearing to be pushy is asking appropriate questions.  It shows that you care and are committed to finding a solution.  Useful questions can come straight from your assessment tool.  For example, “Do you see any evidence of an enlarged prostate?”  or  “Did you notice any evidence a UTI?”

 

Possible Therapies

 

     Even though you are not involved in this process, it is still appropriate to be familiar with the different therapeutic choices.

 

Pharmacological Interventions

 

1.) Reevaluation Of Meds

 

Diuretics

 

     Diuretics (water pills) make a person go to the bathroom.  They have a great impact on bladder control.  If the water pill is aggravating the incontinency problem, their use could be altered. Some examples of Diuretics are furoesmide (Lasix), hydrochorlothiozide (HCTZ) and spironolactone (Aldactone).  Caffeine is a Diuretic.  Its consumption should also be evaluated for its impact.

 

AFC provider consideration:  An important aspect of Diuretic medication use is that they should be taken in the morning, when they will have less of an impact on urinary function.

 

Muscle relaxers, anti-anxiety and other relaxants

 

     Sphincter and bladder muscles may be affected by these meds and contribute to the loss of bladder control. Cognitive function reduction may also affect the patient’s ability to make it to the bathroom on time.

 AFC Consideration: Most drug relaxants are used on an as needed basis and are somewhat under your control.  As you decide if they are needed or not, you should consider how much the relaxant effect is contributing to the loss of bladder control.

  

2.) Adding New Meds

 

Bladder Spasm Reducers

 

     There are a number of medications that can be used to reduce the urgency to urinate caused by bladder spasms.  Most work on the nervous system of the urinary tract.  Some examples are oxybutynin (Ditropan), tolterodine (Detrol LA), solifenacin (Vesicare) and flavoxate (Urispas).

 

AFC consideration: For patients with swallowing problems, only plain oxybutin can be crushed.  It also comes as a liquid and a patch.  There are side effects and concerns with theses meds.  These should be discussed with a pharmacist or doctor.  Be sure to read the drug information given with the prescription.

 

Behavioral Therapies

 

     Many incontinency problems can be reduced or eliminated with some focused efforts from the patient.  These therapies have the added benefit of giving some control back to the patient, and increasing his or her image of self worth and independence.  Before initiating any therapy, you must consult with a doctor. The mental capabilities of the patient have to be taken into consideration as well. 

 

1.) Bladder Retraining

 

     The goal of bladder retraining is to regain control of the bladder despite frequent urges to urinate.  Therapy : Bathroom trips are scheduled, usually every 2 hours.  If there is an urge to go between times you should stand or sit still.  Concentrate on contracting the sphincter muscles until the urge passes.  Deep breaths with slow exhaling can help.  Once the urge is under control, walk slowly to the bathroom to void. After 2 days without leakage scheduled bathroom trips can be increased by 30-60 minutes.  The end goal is urination every 3-4 hours. 

AFC consideration; Patience and follow through are required and may take several weeks of practice.  This therapy is good for stress and or urge incontinency. 

 

2.) Pelvic Muscle Exercises (kegel exercises)

 

     Kegel exercises are isometric strength tuning of the pelvic muscles.  Therapy: Start out by concentrating on just the pelvic muscles and then squeeze them, trying to keep the surrounding muscles of the legs, abdomen and buttock relaxed.  Squeezing the wrong muscles can put pressure on the bladder.  Tighten the pelvic muscles for a count of 3, then relax for a count of three.  Work gradually up to 10 sets, 3 to 4 times a day.  This exercise can show improvement in 3 to 6 weeks.

 

AFC consideration: This is an exercise and should not be overdone.  If there is a need, lying down makes the exercise easier. Scheduled exercise times will help the patient remember. If therapies are too difficult for you to start, you could ask the doctor to prescribe a physical therapist to do the initial training.  Regular walks facilitate these exercises.

 

3.) Prompted Voiding

 

     Basically, this a fancy name for scheduled toilet trips, regardless of need.  This is particularly useful in functional incontinency.  You’re probably using some form of this already.  Positive reinforcement helps to entrench proper toiletry habits.

 

The Fifth Step to control – Follow-through

 

     Once therapy and medications are determined, you must do what AFC providers do best.  Give individual, consistent follow-through for each case.

Important points to remember:  

1.  An essential part of follow-through is measuring the outcomes of the therapies. Without measurements, you won’t be able to tell if you are having any success.

2. Keep the doctor informed. Report on the measurements that you have taken.  

3. Careful consideration of appropriate Incontinency products should be tailored to meet individual needs.  Do not rely too much on these products, as they can become a crutch. The goal is reduce their use or not use them at all.

 

 Adult Diapers

 

    While therapy is being started or if the problem is not entirely eliminated, adult diapers can be very helpful.  They come in a wide variety of styles and coverage.  You, as a professional care provider, must familiarize yourself with the available choices and choose one that enables your therapy efforts.  As the therapy succeeds, don’t be afraid to change the diapers or pads accordingly.

 

Catheters

 

     Catheters, in my opinion, should be used only as a last resort.  They are very demeaning, hard to take care of and prone to cause infections.

 

AFC Bonus Section  

I would like to pass on a few tricks that I have learning in my 18 years in AFC and 12 as a pharmacist.  I hope they will save you time, energy and protect your property too.

 

1. Pet odor eliminating products, like in carpet shampoos and furniture cleaners, can be very useful in making accidents go away. 
2. Large garbage bags can save a chair.  1. Place the large garbage bag around the chair cushion.  2. Safety pin a large towel (that matches the chair) on top of the cushion.  This hides the garbage bag from view and if there is an accident you simply wash the towel and replace the garbage bag.
3.  Mattresses can be similarly protected. 1. Cut the garbage bag length wise so when laid flat it will cover the entire width of the bed.  2. Place it under the fitted bottom sheet, where the patient’s bottom will lie. 3. Instead of using a towel, use a regular (non-fitted) sheet (a draw sheet). The draw sheet will stay in place if you:  a.) fold it lengthwise four times. b.) place the folded draw sheet over the bottom sheet where the bottom of the patient will lie.  c.) Put it lengthwise over the width of the mattress so that you can tuck a good portion of it under each side of the bed.  This will also hold it and the garbage bag in place.  If frequent wetting is an issue, placing the garbage bag over the bottom sheet might save some laundry.  You can buy bed liners (blue chucks) that will do the same thing, but garbage bags and draw sheets stay in place better and are a fraction of the cost.
4. Scheduled potty breaks are a must.
5. Scheduled fluid intake can also help avoid issues, especially at night.  Controlling fluid intake can also help ensure the patient gets adequate hydration. Consult with the doctor how much fluid intake is proper for each patient.

 

Conclusion

     Though incontinency will remain a challenge to elderly care in the foreseeable future, it does not mean that there will be a loss of dignity, independence or property value.  If you are consistent with therapies and diligent with hygiene, the consequences of incontinency can usually be reduced or eliminated.  Remember the old saying:  “If you work at it hard – it’s easy.  If you work at it easy – it’s hard.”

     Good luck.

 

References:

1. Urinary Incontinence in Women. NIH Publication No. 08–4132 October 2007, National Kidney and Urologic Diseases Information Clearinghouse. http://kidney.niddk.nih.gov/kudiseases/pubs/uiwomen/

2. Urinary Incontinence, also call overactive bladder. MedlinePlus.

http://www.nlm.nih.gov/medlineplus/urinaryincontinence.html

3. Incontinence Overview, Incidence & Prevalence of Urinary Incontinence. Health Communities.com

http://www.urologychannel.com/incontinence/index.shtml

4. Urinary incontinence, Wikipedia, The Free Encyclopedia

. http://en.wikipedia.org/wiki/Urinary_incontinence

5. Urinary Incontinence. MayoClinic.        

http://www.mayoclinic.com/health/urinary-incontinence/DS00404

  

Incontinency: Trying to Control the Uncontrolled

 

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