Incontinence | Just the Facts

What is incontinence? It is the inability to control the passage of urine and feces-a common but not inevitable symptom in aging, but it is often reversible. Incontinence of urine is more common than fecal incontinence. The condition is more common in women than in men.

One day Mrs. Smith said "growing old wouldn't be so bad if our parts all wore out at the same time." This was said with a twinkle in her eye. What prompted her to make the comment? This 86-year-old lady functioned very well except for two problems. First, she just hadn't have the energy she once had, so she couldn't take are of herself properly. Second, she was unable to control her bladder, which caused her a great amount of embarrassment.

She was fearful to go shopping, even for food, or attend a moving or visit a friend. She was even afraid of what might happen if someone visited her. She had no warning that her bladder would empty. If she did she could not move fast enough to get to a bathroom.

Incontinence if frequently one reason why families choose to institutionalize a relative. They simply can't manage and cope with the problem at home on a 24-hour basis.

The Significance of Incontinence

Consider the emotional, social and physical significance of losing control of bowel and/or bladder on both the individual who has the problem and on those near by.

Infantalization

What could make a person feel less like an adult than wetting oneself? This problem often happens at a time when older persons are losing control over much of their lives. For nursing home residents who feel they have given up so much already (home, joy, community), incontinence can be the extra problem that saps their will to keep trying.

Nursing home staff, who may not appreciate their sensitivity, inadvertently may further infantilize the resident by speaking in motherly tones ("Oh, you've wet your pants again.") or scolding ("You know better than that.") Adults are expected to take responsibility for themselves, but the incontinent adult cannot.

Smell

There is no lasting odor around an incontinent resident who is well cared for. However, if an accident has just happened, order will be a momentary problem. The resident naturally feels embarrassed.

Containment Pads

A resident who has been adequately diagnosed and who cannot be successfully treated medically or behaviorally may need to use adult containment pads. These can add a measure of confidence. However, they also may be demoralizing to the individual's self esteem. Many facilities avoid the use of the word "diaper" since it is associated with infants.

Skin Breakdown

A resident who is repeatedly wet or soiled requires good skin care to prevent pressure sores from developing. For good skin care, the resident's position must be changed at least every two hours. If the resident is in bed, turning from side to back to other side is required; if sitting, then standing is required.

Every time a resident eliminates urine or feces, the clothes are changed and the buttocks and area between the legs are washed and dried. The skin is massaged to increase circulation. Although good skin care requires additional staff time and may be embarrassing for the resident, it is extremely important and necessary as a preventive measure against skin breakdown.

Is urinary incontinence untreatable? What are the causes? Incontinence is very complicated; however, at least 50 percent of those who experience incontinence can be helped. Incontinence is no longer considered part of old age, which is accepted. Physicians and nurses together often can diagnose the problem and plan a treatment program. You, as the family and friend of the resident, can be helpful in the diagnosis of the cause as well as the treatment of the condition.

Causes of Urinary Incontinence

There are four major causes of urinary incontinence: environmental, psychological, drugs and disturbance of the urinary system. You can help by providing information on the resident's history to aid in diagnosis.

If you know the resident well, your information is important. For example, suppose Mrs. Smith urinates in her bed at night. The nurse may ask you if this also happened at home. If it started after admission to the nursing home, the problem could be as simple as helping Mrs. Smith to the bathroom at night. In a strange environment, she may be too frightened to get up at night. If the bed rails are up, she may be unable to get the bathroom.

Your input would make quite a difference. These are environmental factors. In fact, Mrs. Smith may confide in you that she can't get up at night. It is important to inform the staff of her concerns and fears.

If environmental factors are not the cause, Mrs. Smith might be reacting to her placement in the home. Your continued support is essential to adjustment and recovery.

The physician may begin or increase a medicine, which can cause incontinence. The usual culprits are medications such as diuretics, which are sometimes given to people with heart disease. The drug helps the body get rid of extra fluid by increasing the need to urinate.

The staff needs to know if your friend or relative was continent prior to taking these medications. Sometimes the dose, the drug itself or the timing is changed to decrease the incontinent effect. If the problem is caused by a drug, it is important psychologically for the resident to know this.

Finally, there are a number of other conditions, such as infection, which cause incontinence. To ascertain this you may be of help by confirming the duration of incontinence. When did it start? How often does it happen?

Of course, the nursing home will ask the resident these questions first, but they may want your confirming opinion. Sometimes residents are reluctant to speak about the problem and/or find it difficult to be accurate about times and frequencies.

Although fecal incontinence is not as common, establishing a history is the first step in the diagnostic process. The causes fall into the same four categories: psychological, environmental, disturbances in the gastrointestinal system and drug related.

Treatment of Incontinence

Once the cause is established, a plan of treatment is ordered by the physician. The cause, of course, dictates the treatment. Drugs to cure infection or even surgery to clear an obstruction may be necessary to control some disturbances. You must be supportive to your friend or relative in these instances.

In other cases, bowel and bladder training is helpful. This approach is designed to re-institute normal bowel and bladder function through a process of communication, fluid intake and habit. Demands on memory are reduced when habits are formed. Fluids are offered on a set schedule every few hours. The resident is also toileted on a set schedule. The bladder becomes filled slowly and triggers the urge to urinate. Gradually the resident becomes accustomed to a natural rhythm and in many instances begins to regain control.

As the resident succeeds in using the toilet, the staff gives praise to encourage continued appropriate elimination. When the resident does not succeed, the staff will change the clothes but give no praise. However, it will not scold either.

Very careful records are kept so that progress in the training program can be evaluated over a period of weeks or moths. The resident is made a partner in the process, as is the family. Encouragement is needed from as many people as possible. Two major problems that perpetuate urinary incontinence in nursing homes is that the staff may be willing to accept incontinence and the resident and family resign themselves to the incontinent condition.

Confused residents require even greater attention since they cannot actively participate in the retaining program. Efforts to decrease the confusion are initiated to help them become aware of their bodies and surrounding. This approach may involve reality orientation, which is a 24-hour program of reminding the resident who they are and what time of day or night it is. Recreational and occupational programs may be added to stimulate them to feel more responsible for self-care, including toileting.

Bladder problems should be controlled by catheters only under special circumstances. If the cause of incontinence cannot be corrected or the results modified by other techniques, the physician may order a catheter. As a relative or friend, you may question whether all alternatives have been explored. The decision to use a catheter is serious because it can lead to urinary infections. Catheters should not be used as a way to minimize staff work. Rather, their use should be appropriate to the situation.

You may ask, how do I know if my relative really needs a catheter? Ask. There are legitimate reasons for its use. Bladders are effected by diseases such as multiple sclerosis. Then a catheter is needed to empty the bladder. A resident who is emaciated, wasted and also incontinent may need a catheter. For some residents, the skin becomes so susceptible to breakdown that a catheter is required to prevent massive bedsores. This is an unusual occurrence.

General Rules to Prevent Incontinence

There are a few rules you as family or friend should remember if you invite an older person away from the nursing home.

• Give adequate notice to the staff so they can write down any specific directions in regard to elimination.
• Assess your relative or friend's need for assistance. Can you move that person to the toilet? Are you comfortable in helping or do you need instructions from the staff?
• Plan your trips so that no stairs are involved in order to use a bathroom. For instance, if you are going to a restaurant, find out whether there is a restroom on the ground floor.
• Go to the bathroom yourself every few hours and invite the resident to go at the same time. This avoids having to say "Do you have to go to the bathroom?"
• If you know that an accident is likely to happen, be sure to take extra clothes along. Your attitude (positive or negative) is conveyed to the resident by your manner and tone of voice. Try to reinforce the fact that your friend or loved one is a person who has a problem with incontinence, but not an incontinent person.

In short, incontinence is a difficult problem. These issues can be demoralizing for both resident and staff if not handled by accurate diagnosis of the cause and adequate plans of treatment and care. Be a partner in the process.

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