Continence issues in the elderly

Continence problems are more likely in older patient, but with appropriate training and support, practice nurses can play a valuable role in assessment and management

A recent world census report highlighted a shift towards not just an ageing population but an aged population.¹ Urinary and/or faecal incontinence (FI) is more likely in older than younger persons, apart from those with a significant acquired or congenital disability. However, the health of the older population ranges from active, healthy nonagenarians to chronically ill, functionally- and cognitively-impaired people from their late 60s onwards. Frail older persons tend to be defined as those over the age of 65 with manifold medical conditions, who take multiple medications and need assistance to perform activities of daily living (ADL).² Nurses need to be alert to the fact that symptoms of incontinence may herald a serious underlying condition e.g. multiple sclerosis, benign prostatic obstruction or malignancy, and these signs should not be dismissed as an age-related inconvenience. Bladder and bowel continence screening and assessment, should be available to all patients, where appropriate,³ including those with dementia, since they are as likely as the cognitively intact population to have conditions which precipitate symptoms of stress or urge incontinence and bladder outlet obstruction.

DEFINITIONS

Urinary incontinence (UI) is defined as the involuntary loss of urine that represents a hygienic or social problem to the individual and anal incontinence is described as the involuntary loss of flatus, liquid or solid stool that is a hygienic or social problem.^4,5

EPIDEMIOLOGY

Incontinence tends to be underreported and under diagnosed; it is likely to result in a poor quality of life (QoL) as well as enhancing the risk of side-effects such as urinary tract infection (UTI), skin excoriation, and falls. Incontinence, particularly FI, is a leading cause of admission to residential care when families are unable to continue caring for a relative with the condition.

PATHOPHYSIOLOGY

The elderly with comorbidities e.g. neuropathy, sphincter injury, inflammatory bowel disease or rectal cancer are at increased risk of FI. These conditions may cause impaired sensation and function of anal continence. Similarly, UI is likely to be multifactorial in nature; contributing factors include obesity, diabetes and enlarged prostate. Wheelchair users and those who are dependent on others for assistance to access the lavatory may have episodes of functional incontinence, yet have completely normal anorectal function and a competent urethral sphincter.

CONTINENCE ASSESSMENT

A continence assessment may be carried out by the practice nurse at the patient's local surgery. Continence service personnel will usually provide training and monitor practice until the nurse is competent and feels confident to complete the assessment. The practice nurse may also go on to learn how to perform an ultrasound bladder scan to assess residual urine volume and to carry out a physical examination as appropriate.

For the first appointment, the patient should be asked to bring a frequency/volume record of the quantity and type of fluids taken, as well as the measured volumes of urine output over a period of 3 consecutive days (72 hrs).⁶ This can provide valuable clues as to the type of incontinence experienced and factors which may contribute to urinary incontinence. Similarly, a bowel diary, including the frequency and consistency of stools passed over a period of one week, will aid diagnosis and consequent treatment decisions.

If the patient has mental capacity, obtaining a medical history will include the questions below; otherwise a carer may be able to provide the relevant information:

• General health
• Weight/height
• Fluid intake/restricted fluid intake
• Alcohol and caffeine use
• Smoking history
• Medications
• Pregnancy/childbirth history for women
• History of prostate problems for men
• Menopausal symptoms for women
• Constipation
• Diabetes or symptoms of diabetes
• Impact of symptoms on quality of life (QoL)
• Nocturia/polyuria
• Episodes of incontinence

Prior to a physical assessment, valid consent must be gained and recorded in the patient's notes. The continence assessment may include urinalysis, an abdominal examination and a vaginal examination for women; the latter is done to assess the strength of the pelvic floor muscles and to note evidence of prolapse. Male patients are usually referred to the GP, should a rectal examination be considered necessary, to determine if the prostate is enlarged. Other objective tests may include the following:

• A blood test to measure the PSA (prostate-specific antigen), which can detect the early signs of prostate cancer.
• Post void residual (PVR) urine volumes may be measured using a portable ultrasound bladder scanner. A PVR volume of less than 50ml is considered adequate bladder emptying and in the elderly, between 50 and 100ml is considered normal.⁷ If larger volumes are found further scans and investigations will be necessary and advice should be sought from the local Continence Advisor or a medical colleague.
• Uroflowmetry, which measures urine voided per unit time, can help to identify patients who have bladder outlet obstruction
• The use of urodynamics and transrectal ultrasound should be limited to situations in which the results are likely to benefit the patient, such as in selection for surgery.

MANAGEMENT

Treatment will depend on the type of incontinence identified on initial assessment as follows:⁴

Stress urinary incontinence (SUI) is more common in women than men and involves involuntary leaking of urine on exertion. Pelvic floor muscle training for at least 3 months is the first line treatment, followed by neuromuscular stimulation, medication or surgery if conservative treatment fails.

Urge urinary incontinence/overactive bladder (urge UI/OAB) presents as urgency, with or without urge incontinence, usually with frequency and nocturia. Advice is to reduce caffeine, but a normal fluid intake of approximately 1.5L daily, depending on body weight, ambient temperature and activity, should be maintained. Bladder re-training for at least 6 weeks, anticholinergic medication, and intravaginal oestrogens as appropriate or surgical intervention may be considered.

For mixed SUI and urge UI, treatment can include a combination of therapies prescribed for either stress or urge related incontinence and will be determined by the predominant symptoms.

Overflow incontinence is defined as involuntary loss of urine associated with bladder over-distention in the absence of detrusor contraction; it is more common in men than women. Symptoms include UTI, daytime dribbling, nocturia or nocturnal enuresis, straining to void, passing small urine volumes of 50-100 ml frequently, (normal bladder capacity is 400-600ml). Persistently high PVR urine volumes, greater than 150 ml, may be found on ultrasound bladder scan or catheterisation. If the underlying cause cannot be corrected by treatments such as medication or surgery, prolonged intermittent catheterisation (IC) may be needed in order to prevent damage to the upper urinary tract. IC is recommended rather than indwelling urinary catheterisation to avoid infection, bladder spasm and urethral erosion.

Faecal incontinence as a result of faecal loading, inflammatory bowel disease, irritable bowel syndrome, rectal prolapse, haemorrhoids, anal sphincter damage, spinal lesion, and cauda equina syndrome should be treated with condition-specific interventions. Overflow leaking around impacted faeces requires both the remedy for the impaction and treatment to prevent future recurrences; if rectal interventions are not appropriate or fail to clear the bowel an oral laxative may be offered.⁸ Anal sphincter exercise, bowel retraining, specialist dietary management, rectal irrigation, biofeedback, neuromuscular stimulation, medication, and surgery may be considered.

For functional incontinence, where the patient is unable to reach the lavatory without assistance, treatment of the underlying cause, additional support, continence devices and advice on management may be implemented.

RED FLAGS

Urgent referral for further investigation and treatment must be made on finding visible or microscopic haematuria. Recurrent infections should alert the clinician to other pathology, such as bladder tumour or interstitial cystitis, and women with symptomatic prolapse or a palpable bladder should also be referred.⁶ Urinary incontinence in men is commonly secondary to prostatic change and warrants urgent urological referral.

CONCLUSION

Since FI carries social stigma, active but sensitive case finding may be necessary, particularly in high-risk groups.⁸ Routinely asking patients over 65 years of age about continence-related symptoms is recommended, because of associated physical and psychological morbidity as well as implications for healthcare provision within the community. This is important for women who may have had obstetric injury, and for both women and men with comorbid conditions consistent with increased risk of bladder and/or bowel dysfunction. The importance of symptom assessment, impact on quality of life, physical examination and urinalysis must be recognised so that people and carers may have easy access to evidence-based information about bladder and bowel care that is adapted to meet their specific needs and preferences.

REFERENCES

1.Kinsella K, He W, U.S. Census Bureau, International Population reports, An Ageing world : 2008, U.S. Government Printing Office, Washington DC, 2009;95-09

2.Fonda D, DuBeau C, Harari, D, et al. Incontinence in the Frail Elderly. In: Incontinence, 3rd edition. Abrams P, Cardozo L, Khoury S, et al, eds. Plymouth UK. Health Publication Ltd 2005;1163-1239

3.Department of Health, Essence of Care. Benchmarks for Bladder, Bowel and Continence Care. 2010;Accessed 09.01.2012. http://www.tso.co.uk

4.Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-78

5.Norton C, Conservative Management of Anal Incontinence, In: Sultan A, Thaker R, Fenner D, eds, Perineal and Anal Sphincter Trauma 2007;11: 133-143

6.The National Institute for Health and Clinical Excellence (NICE), Urinary incontinence: the management of urinary incontinence in women, CG40 2006;3

7.Kelly CE, Evaluation of voiding dysfunction and measurement of bladder volume. Reviews in Urology. 2004;6(Suppl 1):S32-S37.

8.The National Institute for Health and Clinical Excellence (NICE), Faecal Incontinence. The management of faecal incontinence in adults. CG49 2007;5