Urinary incontinence (UI), defined as any involuntary leakage of urine, affects over half the population living in post-acute long-term care (PALTC) and costs an estimated 5.5 billion annually, according to the Society for Post-Acute and Long-Term Care Physicians. Moreover, nurses care for residents who express embarrassment in losing control of their bladders and witness the side effects incontinence can cause. Often, the loss of being able to maintain continence—one of the most private activities of daily living performed independently since childhood—causes social isolation and depression. Causing these undesired outcomes and posing risks for the resident as well as the facility, UI warrants the attention of the nurse leader. This article will highlight components of a strategy to systematically address UI.
Provide Education on the Normal Changes of Aging that Contribute to UI
Although a commonly-held misconception assumes that UI is inevitable, this is not true. Nurse leaders are in a position to educate the interdisciplinary team (IDT) about what is and what is not normal aging so that the IDT can draft care plans and performance improvement plans based on sound clinical evidence. While UI is not a normal part of aging, the risk for UI does increase due to normal changes of aging summarized in the table below.
Changes in the kidneys: Beginning in our forties, renal blood flow starts to diminish, as does the mass of the kidney. This in turn affects the nephrons, the filtering units of the kidneys. As we advance in age, the glomerulus, or the place where blood is filtered in the kidney often becomes sclerotic (scarring or hardening). The renal tubules, the part of the nephron that separates what has been filtered and carries waste to the collecting duct, become less efficient at exchanging substances and conserving water and sodium. This puts the older adult at risk for electrolyte imbalances including hyponatremia.  |
| Changes in the bladder and urinary tract: The bladder, which is made up of smooth muscle, connective tissue, and elastic tissue, is where the urine is stored before being excreted from the body. A young adult’s bladder can safely hold approximately 450 ml of urine, but the older adult’s bladder can only hold approximately 250ml – 350ml before leakage occurs. This is because as we age, there is loss of smooth muscle, and the tone, connectivity, and elasticity diminish. Changes in hormone levels, especially decreases in estrogen in women, also contribute to the loss of tone in the bladder muscle. |
| Changes in nervous system: A young adult perceives bladder fullness when the bladder is about half full. The older adult may not start feeling fullness until the bladder is nearly full. This is due in part to degenerative changes in the cerebral cortex. Diminished thirst sensation also occurs with advanced age and often results in decreased fluid intake. Decreased fluid intake causes a fluid imbalance, which in turn decreases urinary output. |
Conduct a Thorough Assessment of Bladder Function
Understanding the normal changes of aging is necessary to conduct a thorough assessment of bladder function so that abnormal changes and risks can be identified during the assessment. In Appendix PP of the State Operations Manual, F690 Incontinence states the following:
§483.25(e)(2) For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that –
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
The intent of this requirement is to ensure that when a resident does have UI, they are assessed and receive appropriate treatment so that a return to normal function can occur, unless there is a reason it cannot be reversed. Continence should be assessed upon admission and then again when a change in continence function occurs. A thorough assessment enables the physician and interdisciplinary team (IDT) to formulate an appropriate and individualized treatment plan.
Appendix PP F690 notes several components that are part of a thorough assessment:
- Type of incontinence
- Prior history of bladder function, including but not limited to type of incontinence and treatment plans
- Voiding patterns
- Medication profile
- Patterns of fluid intake
- Intake of urinary stimulants or irritants
- Pelvic and rectal exam
- Cognitive function
- Physical functional abilities
- Pertinent diagnosis
- Diagnostic tests
- Environmental factors and use of assistive devices
As indicated in the list above, the type of incontinence is part of a thorough assessment. Appendix PP F690 describes multiple types of UI, which are listed in the table below.
| Urge | Is associated with detrusor muscle over activity (excessive contraction of the smooth muscle in the wall of the urinary bladder) resulting in a sudden, strong urge (also known as urgency) to expel moderate to large amounts of urine before the bladder is full). It is characterized by abrupt urgency, frequency, and nocturia (part of the overactive bladder diagnosis). It may be age-related or have neurological causes (e.g., stroke, diabetes mellitus, Parkinson’s disease, multiple sclerosis) or other causes such as bladder infection, urethral irritation, etc. The resident can feel the need to void but is unable to inhibit voiding long enough to reach and sit on the commode. It is the most common cause of urinary incontinence in elderly persons. |
| Stress | Is associated with impaired urethral closure (malfunction of the urethral sphincter) which allows small amounts of urine leakage when intra-abdominal pressure on the bladder is increased by sneezing, coughing, laughing, lifting, standing from a sitting position, climbing stairs, etc. Urine leakage results from an increase in intra-abdominal pressure on a bladder that is not over distended and is not the result of detrusor contractions. It is the second most common type of urinary incontinence in older women. |
| Mixed | Is the combination of urge incontinence and stress incontinence. Many elderly persons (especially women) will experience symptoms of both urge and stress. |
| Overflow | Is associated with leakage of small amounts of urine when the bladder has reached its maximum capacity and has become distended from urine retention. Symptoms of overflow incontinence may include: weak stream, hesitancy, or intermittency; dysuria; nocturia; frequency; incomplete voiding; frequent or constant dribbling. |
| Functional | Refers to loss of urine that occurs in a resident whose urinary tract function is sufficiently intact that he/she should be able to maintain continence, but who cannot remain continent because of external factors other than inherently abnormal urinary tract function. Examples may include the failure of staff to respond to a request for assistance to the toilet, or the inability to utilize the toilet facilities in time. |
| Transient | Refers to temporary or occasional incontinence that may be related to a variety of causes, for example: delirium, infection, atrophic urethritis or vaginitis, some pharmaceuticals (such as sedatives/hypnotics, diuretics, anticholinergic agents), increased urine production, restricted mobility or fecal impaction. The incontinence is transient because it is related to a potentially improvable or reversible cause. |
Implement Individualized Interventions
The findings from the bladder assessment, along with the resident’s cognitive and physical abilities, desire to comply with a behavioral program if it is indicated, ability to feel the urge to void, as well as the ability to control the urge must all be considered when planning the course of treatment. Appendix PP F690 includes several interventions to consider, which are noted in the table below (this is not an all-inclusive list).
| Bladder Rehabilitation/ Bladder Retraining | A behavioral technique that requires the resident to resist or inhibit the sensation of urgency (the strong desire to urinate), to postpone or delay voiding, and to urinate according to a timetable rather than to the urge to void. Depending upon the resident’s successful ability to control the urge to void, the intervals between voiding may be increased progressively. Bladder training generally consists of education, scheduled voiding with systematic delay of voiding, and positive reinforcement. This program is difficult to implement in cognitively impaired residents and may not be successful in frail, elderly, or dependent residents. |
| Pelvic Floor Muscle Rehabilitation | Also called Kegel and pelvic floor muscle exercise, is performed to strengthen the voluntary periuretheral and perivaginal muscles that contribute to the closing force of the urethra and the support of the pelvic organs. These exercises are helpful in dealing with urge and stress incontinence. PFMR requires residents who are able and willing to participate and the implementation of careful instructions and monitoring provided by the facility. |
| Prompted Voiding | A behavioral technique appropriate for use with dependent or more cognitively impaired residents. Prompted voiding has three components: regular monitoring with encouragement to report continence status; prompting to toilet on a scheduled basis; and praise and positive feedback when the resident is continent and attempts to toilet. Prompted voiding focuses on teaching the resident, who is incontinent, to recognize bladder fullness or the need to void, to ask for help, or to respond when prompted to toilet. Residents who are assessed with urge or mixed incontinence and are cognitively impaired may be candidates for prompted voiding. |
| Habit Training/Scheduled Voiding | A behavioral technique that calls for scheduled use of the bathroom at regular intervals on a planned basis to match the resident’s voiding habits. Habit training includes timed voiding with the interval based on the resident’s usual voiding schedule or pattern. Scheduled voiding is timed voiding, usually every three to four hours while awake. Residents who cannot self-toilet may be candidates for habit training or scheduled voiding programs. |
| Pessary | An intra-vaginal device used to treat pelvic muscle relaxation or prolapse of pelvic organs. If a pessary is used, the plan of care must address the use, care and ongoing management of the pessary, including monitoring for complications. |
Collaborate with Vendors to Manage the Use of Products
When continence is not possible, the use of absorbent products and skin products, including incontinence briefs or pads, cleansers, and barrier creams, is necessary. These products, especially absorbent products, are one of the most expensive supply costs. Therefore, it is critical that nurse leaders, as fiscal stewards for the facility, consider what products will be most cost effective while still being appropriate and comfortable for the residents. The nurse leader should consult with the facility’s vendors and review the formulary or list of products that are available for order. The vendor can answer questions about the efficacy of the products to protect the skin and can assist with a cost benefit analysis when considering a new product.
Another key issue a vendor can assist with is establishing protocols to assess residents for the type and size of incontinence products they need. This can help to ensure the appropriate product is in place, with consideration given to the type of incontinence the resident has, their physical and cognitive status, and other factors pertinent to selecting products. The type and size of incontinence products will need to be re-assessed as the resident changes. For example, if the resident gains weight and uses an incontinence brief, re-sizing the incontinence brief may be necessary. Once products are selected, many vendors will provide the staff with the education they need to use the products correctly.
Summary
UI is a widespread problem, and a challenging area of care for nurse leaders to address. The nurse leader’s knowledge of the normal changes of aging will help the IDT complete thorough assessments of continence function and implement individualized plans of care to help maintain the residents’ dignity and highest functional ability. When continence is no longer possible for a resident, the nurse leader can collaborate with vendors to continue to maintain a resident’s dignity, protect their skin, and manage the use of supplies in a fiscally responsible manner.
Note: AAPACN offers an in-service for certified nurse aides on the topic of urinary incontinence, Basics of Care for the Resident Who Has Urinary Incontinence.
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