Estimates of the incidence of incontinence in hospitalized elderly patients range from 13 to 48% while estimates of the incidence of incontinence in elderly citizens living in the community range from 1.6 to 42%. ' The personal consequences for the incontinent individual, his family, and those who care for him are enormous. Despite the magnitude of the problem, review of the nursing literature reveals little information on the care of the incontinent client. The purpose of this paper is to review the nature of incontinence and to delineate appropriate nursing strategies which may be used in working with the incontinent client.
The Nature of Incontinence
Incontinence may be broadly defined as "the passage of urine in an undesirable place."2 It is a symptom which may result from one or a combination of factors. Although increased attention has recently been given to precise specification of the condition, a standard nomenclature for discussion of the problem does not yet exist. Some discussions use the nature of the presenting symptoms as a basis for classification. Thus one may read of stress incontinence (leakage of urine on coughing or straining) or urge incontinence (precipitate voiding without control). Some authors have focused on mechanical forces involved in the micturation process and have distinguished between active and passive incontinence.2'3
Many authors have used etiological factors as a basis for classification of incontinence in the elderly. A primary concern in many of these discussions is the need to distinguish between incontinence due to self-limiting and/or environmental factors and that which is due to long lasting and/or physiological factors. Thus Brocklehurst4 speaks of transient incontinence (a condition which accompanies acute disease states) and established incontinence (that which continues after the disease has been treated), while Newman5 distinguishes between apparent incontinence (that due to situational factors) and true incontinence (that due to neurogenic or traumatic factors).
Willington6 also identifies two major categories of incontinence: (a) spurious incontinence resulting from environmental factors; and (b) central incontinence caused by physiological factors. Willington further categorizes spurious incontinence as that caused by either iatrogenic or associated factors. Iatrogenic causes are those resulting from treatment. Primary among these is drug therapy such as the use of diuretics, sedatives, and hypnotics. Associated factors which lead to spurious incontinence include locomotor defects, loss of manual dexterity, and distance to the toilet.
True or Central Incontinence
Understanding and prevention of apparent or spurious incontinence depends on intelligent and thoughtful nursing care. Understanding and management of true or central incontinence depends on further knowledge of the mituration process and the factors which may affect this process.
The micturation process involves the bladder, supporting muscles, and a system of nervous control. The bladder is composed of two parts: (a) the body, composed primarily of the detrussor muscle, and (b) the bladder neck. The bladder is supported on the muscular pelvic diaphragm. Resistance at the bladder neck is normally maintained by smooth muscle and elastic tissue. In recumbent positions, this resistance is sufficient to prevent passage of urine.
When pressure on the pelvic floor is increased, however, either by standing Or by increased intra-abdominal pressure, two muscular sphincters provide the mechanism for the maintenance of continence: (a) the internal urethral sphincter, composed of muscles of the pelvic diaphragm and controlled by the autonomic nervous system; and (b) the external urethral sphincter, a voluntary skeletal muscle controlled by the pudendal nerves.
The conscious and controlled act of voiding depends on an intact neural pathway composed of autonomic nerve fibers in the bladder, a sacral bladder center located in the S2-S4 segment of the spinal cord, and a cortical bladder center located in the frontal cortex. The basic act of micturation involves a reflex arc. As the bladder begins to fill, stretch receptors located in the bladder wall are stimulated and impulses are conducted from the sacral bladder center hack to the bladder through parasympathetic fibers and bladder contractions are initiated. At a certain point, a large contraction of the detrussor muscle occurs, the muscles of the pelvic diaphragm are relaxed and the bladder empties. This reflex arc of micturation con trois the act of voiding in the infant.
Impulses which convey the sensation of bladder distension are also conducted from the sacral bladder center to the cortical bladder center. Control of voiding Occurs in two ways. Impulses which block the micturation reflex are transmitted back to the sacral bladder center and tonic contraction of the external sphincter is maintained. The older child and adult is thus able to control the time and place of voiding.
Etiology of Incontinence
The bladder of the elderly individual, who is incontinent or not, is normally altered in three ways: (a) bladder, capacity; (b) quantity of residual urine; and (c) presence of uninhibited bladder contractions. As Brocklehurst7 states:
In a normal younger person bladder capacity is 400-600 ml, residual urine is absent and uninhibited bladder contractions do not occur. In older people who are not incontinent, bladder capacity diminishes and the amount of residual urine increases. Thus the bladder neither fills properly nor empties properly. In addition, large uninhibited bladder con Ira étions may occur during filling and may empty the bladder precipately.
In addition to normal changes associated with aging, pathological alterations occur which precipitate the state of incontinence. Brocklehurst and Hanley8 identify five causes of incontinence: (a) disorders of the pelvic diaphragm; (b) disorders of the urethra and bladder outlet; (c) disorders within the bladder; (d) disorders of the neurological control of micturation; and (e) the unstable bladder (Figure 1).
Disorders of the Pelvic Diaphragm
Elderly females frequently manifest symptoms of urinary incontinence associated with disorders of the pelvic diaphragm. The muscles and structures of the pelvic diaphragm are normally weaker in females than in males. Further, in the aging process, muscle tissue is decreased and is replaced by adipose connective tissue, a process much more marked in females than in males. Pelvic support structures in females are further weakened by lack of estrogen.9
When pressure on the pelvic floor is increased such as by standing, coughing, sneezing, or laughing, a small amount of urine may be released. This condition is known as stress incontinence and is estimated to be present in 12% of elderly females.7
Disorders of the Urethra and Bladder Outlet
Factors leading to disorders of the urethra and bladder outlet differ in males and females. In both sexes, a common cause of urinary incontinence is a fecal impaction which obstructs urine flow. In males, however, the most common cause of bladder outlet obstruction is benign prostatic hypertrophy. In women the condition is less frequent but may be caused by trigonitis associated with senile vaginitis.
Disorders of the Bladder
Any disorder of the bladder such as carcinoma or a calculus may cause incontinence, but the most common cause is an acute cystitis or urinary tract infection.
Disorders in Neurological Control
Disorders at any point in the neural pathway governing micturation can result in incontinence. These disorders are usually classified as one of four types:
1 CAUSES OF CENTRAL
1. Autonomous neuropathic bladder. There is damage to the sacral bladder center and a breakdown of the primary reflex arc.
2. Atonic neuropathic bladder. There is damage to the posterior nerve root and loss of sensation of bladder distension.
3. Reflex neuropathic bladder. There is damage to the spinal cord between the sacral and cortical bladder center with loss of sensation of bladder distension and the ability to inhibit reflex contractions.
4. Uninhibited neuropathic bladder. There is damage to the cortical bladder center with loss of ability to inhibit reflex contractions; some sensation of bladder distension is retained.
Of this group, the uninhibited neuropathic bladder is of primary significance in the care of the elderly client. Damage to the cortical bladder center may result from cerebrovascular accidents, from diffuse arteriosclerotic changes, and from loss of neuronal function with the aging process. Thus many elderly individuals exhibit symptoms associated with an uninhibited neuropathic bladder. As the bladder fills, bladder contractions are initiated and the individual recognizes a need to void. He is unable to inhibit reflex contractions, however, and so must void quickly. Since bladder capacity is decreased, he must void more often. Thus one sees the individual who must arise several times during the night to void; when he recognizes the need, he must void quickly. This condition, inability to control voiding after the need is recognized, is known as urge incontinence.
The Unstable Bladder (Detrussor Instability, Detrussor Hyperreflexia) .
Brocklehurst and Hanley8 identify as a fifth cause of incontinence, the Unstable bladder. The unstable bladder represents impairment of bladder control without demonstratable central nervous disease; local abnormalities may be present around the bladder. Uninhibited contractions of the bladder occur in response to diverse stimuli such as coughing or sudden movement.
Incontinence caused by both the unstable bladder and by disorders of the pelvic diaphragm is manifested as the passage of urine with increased abdominal pressure, ie, on coughing or sneezing. However, the two types of incontinence may be distinguished. Incontir nence resul ting from disorders of the pelvic diaphragm (stress incontinence) is associated with leakage of a small amount of urine. In the unstable bladder, stimuli lead to uninhibited bladder contractions which may be associated with a sense of urgency; these contractions result in the total or almost complete emptying of the bladder.
In .summary, incontinence in the elderly is the result of two major factors. The first of these is uninhibited bladder contractions, caused by either CNS disease (the uninhibited neuropathic bladder) or by localized conditions (the unstable bladder), and associated with sensations of urgency and almost total bladder emptying. In elderly females, stress incontinence, caused by weakening of the pelvic diaphragm may be a problem. This condition is manifested by the loss of small amounts of urine on coughing or laughing, etc.
The Medical Treatment of Incontinence
The first step in the treatment of incontinence is the accurate diagnosis of the type of incontinence present. This diagnosis may, in some cases, be made from a thorough history and physical and a record of the pattern of incontinence demonstrated by the patient. A cystogram, micturating cystogram, cystoscopy, and intravaneous pyelogram may be required for an accurate diagnosis. Any underlying pathology leading to the condition, such as an acute urinary tract infection or benign prostatic hypertrophy, is first treated. Treatment of incontinence falls generally within three categories: (a) physiotherapy and electrical stimulation, (b) drug therapy, and (c) surgical procedures.
Physiotherapy and Electrical Stimulation
The aim of such treatment is to improve muscular tone of the pelvic diaphragm. The patient may be taught exercises similar to those used for antepartal patients. Electrical devices may be used to stimulate the patient to contract the muscles of the pelvic diaphragm. These methods are, however, beneficial only in the treatment of stress incontinence.
Drug therapy in the treatment of incontinence has been directed primarily at decreasing uninhibited bladder contractions. As Brocklehurst7 states:
The basic cause underlying the incontinence of old age is release of the sacral reflex bladder mechanism from inhibiting influences arising within the brain with resulting over-excitability of this basic reflex. It therefore, seems logical to attempt to diminish the incidence of uninhibited contractions and to increase bladder capacity by blocking transmission of nervous impulses somewhere within the sacral reflex arc,
Anticholinergic drugs are used for this purpose. The sacral reflex arc is mediated by parasympathetic nerve fibers. These are cholinergic nerve fibers, thus drugs which block nerve impulses in these fibers, ie, anticholinergic drugs are used in treatment. Drugs used include belladonna, atropine, propantheline, orphena- drine, Imipramine, emephroninium bromide (Cetiprin) and flavoxate (Urispas). The latter two are the most commonly used.8
Surgery is directed at realigning the bladder with support surfaces. A primary factor is elevation of the bladder neck. The procedure in no way effects uninhibited bladder contractions and is useful, there- fore, only in the treatment of disorders of the pelvic diaphragm (stress incontinence).
In summary, medical management of incontinence resulting from disorders of the pelvic diaphragm includes pelvic exercises and surgery. Treatment of incontinence resulting from uninhibited bladder con- tractions, whether from an uninhibited neuropathic bladder or unstable bladder, consists primarily of the administration of anticholinergic drugs.
The process of nursing involves assessment, plan- ning, intervention, and evaluation.
Accurate and thorough assessment forms the founda- tion of the nursing plan. Assessment of the incontinent patient may be broadly divided into two categories: physiological and environmental factors.
Patterns of micturation. It is essential that the nurse understands thé pattern of the patient's voiding and his incontinence. Data should be collected regarding the patient's normal pattern of voiding. This should include:
a. Frequency of voiding both during the day and at night: Nocturia may be a particular problem for the elderly client. Factors which contribute to this problem include decreased bladder size and decreased ability of the aged kidney to concentrate urine."
b. Duration between urge and voiding: As noted earlier, the elderly patient may have percipitant voiding. The length of time the patient is able to control voiding after becoming aware of the urge to void is of major significance.
c. Other symptoms of dysuria: Incontinence is frequently associated with a urinary tract infec- tion or benign prostatic hypertrophy. Symptoms which may be indicative of these or other problems should be noted: appearance of urine (color, odor, presence of sediments); pain or burning on urination; and difficulty starting or stopping the stream of urine.
The pattern of the patient's incontinence can be ascertained by collecting the following data:
a. Time: The client may be incontinent only at night or at certain periods during the day.
b. Place: Many environmental factors, to be dis- cussed, contribute to the patient's incontinence. Incontinence which occurs only when the patient is confined to bed or at a great distance from the toilet may be indicative oí such factors.
c. Amount: The amount of urine passed, whether a small or large amount, should be noted. Patients with stress incontinence typically lose only a small amount of urine while those with incon- tinence due to bladder instability more frequently are incontinent of large amounts.
d. Provoking stimuli: If possible, stimuli which provoke the incontinence such as laughing or coughing should be noted.
e. Patient awareness: It should be noted whether the patient is aware of the need to void and unable to control the response or unaware of the need.
These data may be most easily collected through the use of an incontinence chart kept over a period of days. The patient should be observed at least every four hours around the clock and a note made of the time, place, whether wet or dry, and if incontinent, the estimated amount of urine. Specific information regarding stimuli and awareness may be obtained by patient interview or, if this is not feasible, may be collected if observations of discrete incontinent events are made.
Mobility and manual dexterity. The patient's ability to easily reach and use the toilet should be assessed. This includes his ability to first identify the toilet, to ambulate to it, and to manipulate his clothing with ease. Many elderly patients are unable to control voiding for more than seconds or minutes after the urge is noted. Slow, painful mobility, and loss of dexterity frequently are the precipating factors in a patient's incontinence.
Symptoms of associated or underlying conditions. Incontinence is frequently associated with other physiological conditions.* Data should be collected with reference to the following symptoms:
a. Urinary tract infection: Pain or burning on urination, frequency, urgency and fever;
b. Senile vaginitis: Vaginal itching and vaginal discharge; and
c. Fecal impaction: Constipation or diarrhea, the presence of a fecal mass as demonstrated by digital examination.
Drug Therapy. Drugs which the patient is receiving for other conditions may contribute to his inconti- nence. These drugs fall principally into three classes: diuretics, sedatives and hypnotics, and anticholinergic drugs.
Diuretics increase the frequency of voiding and may lead to a sense of urgency which the patient is unable to control. Particularly troublesome are the fast-acting diuretics such as furosemide (Lasix). It should be noted whether the patient is receiving any diuretic agents. If so, their time of administration and duration of action should be noted in relation to the patient's inconti- nence pattern.
Sedatives and hypnotics may depress the patient's level of awareness of bladder distension. Some patients may be incontinent only at night after the administra- tion of a hypnotic. The administration of sedatives or tranquilizers during the day may sufficiently lower the patient's awareness to contribute to his incontinence. The administration of drugs in "normal" dose ranges may oversedate the elderly client for absorption, distribution, metabolism, and elimination of drugs is altered in the elderly.12 Drugs which frequently contribute to this problem are diazepam (Valium) and the phenothiazines.11 The nurse should observe whether the patient is receiving sedatives and hypnotics and if there is a relation between their use and his incontinence. If the drugs are ordered on a Ρ RN basis, assessment of the need for their administration should be made.
Anticholinergic drugs are used in the treatment of urinary incontinence but· their use may also para- doxically contribute to the problem. When used in the treatment of incontinence, they block the sacral bladder reflex and decrease uninhibited bladder contractions. When used in the patient with a normal bladder or when used in large amounts this same action may result in a bladder with very little tone. The result is urinary retention and overflow incontinence. Two groups of drugs commonly prescribed for elderly clients have these effects, the tricyclic antidepressants and the anticholinergic drugs used in the treatment of Parkin- son's disease. Drugs in the first category include Imipramine (Tofranil) and amitriplyine (Elavil), while those in the latter category include orphenadrine (Disipal) and biperiden (Akineton). The nurse should determine whether the patient is on any medication which has anticholinergic effects and if so, whether the patient's incontinence seems to occur with a full bladder.
The atmosphere of the unit. The nurse must assess the atmosphere of the unit and determine the behav- ioral clues communicated to patients. There is much evidence that behavior is influenced by the expectations of others. Does the atmosphere of the unit indicate to the patient that he is expected to be continent or incontinent? Wells13 demonstrates the manner in which a message of incontinence is communicated:
In one ward dayroom every chair seat was observed to be covered with an incontinence pad. Dresses were folded in front so that their knickerless backsides were safely on paper. While the chairs were certainly protected, the obvious message to patients in that room was "wet yourself."
Physical setting. Toilets on the unit should be clearly identified, there should be sufficient numbers so patients do not have to wait, and most importantly, they should be at a close distance. It has been estimated that elderly, ambulatory patients can walk no more than 15 m (50 ft) once the urge to void has been noted.14 If such facilities are not available, it should be noted whether toilet alternatives, such as bedside commodes are available.·
The plan of care should be a joint venture between the nurse and the physician. The nurse has collected a variety of data regarding biopsychosocial variables; the physician has collected specific information from diagnostic tests. Collation of these data provides an adequate base for an accurate diagnosis of the patient's urinary difficulty.
It is the physician's responsibility to diagnose the nature of the incontinence, to treat any patho- physiological conditions, and to prescribe drug therapy. Manipulation of environmental factors and patterning of the days', activities may be undertaken by the nurse.
Four approaches to the problem of incontinence may be identified: (a) alleviation of causes of spurious incontinence; (b) pelvic floor exercises; (c) bladder retraining; and (d) behavior therapy. These may be used separately or in combination.
Alleviation of Causes of Spurious Incontinence
Spurious incontinence is a condition preventable by intelligent nursing care. Analysis of the data collected during assessment provides the basis for the interven- tion and should indicate problem areas, such as drug therapy or limited mobility. Intervention is then tailored to correct specific problems for each patient. For example, if it has been noted that the administra- tion of PRN tranquilizers on a routine basis seems to contribute to the patient's incontinence, a revised schedule, based on assessed need only, may be implemented.
Pelvic Floor Exercises
If the physician has identified weakness of the pelvic diaphragm as the cause of incontinence, pelvic floor exercises may be useful. These exercises carried out over a period of two to three months are designed to strengthen the muscles of the pelvic floor. Mandel- stam15 describes these exercises:
1. Sit, stand, or lie comfortably, without tensing the muscles of the seat, abdomen, or legs, and pretend your are trying to control diarrhea by tightening the ring of muscle around the anus. Do this several times until you feel certain that you have identified the right area and are making the correct movement.
2. Sit on the commode and start to urinate, and while doing so make an attempt to stop the flow in mid-stream by contracting the muscles of the pelvic floor surrounding the urethra and vagina. This should be carried out several times until you feel sure of the movement, and of the sensations of applying conscious control.
3. Exercise as follows: sitting, standing, or lying, tighten first the anal sphincter and then the front, and then both together. Count four slowly, and then release the muscles. Do this four times, repeating the whole sequence once every hour, if possible. With practice the movements should be quite easy to master and the exercises can be carried out any time-while waiting for a bus, standing at the sink, watching television, or even lying comfortably in bed.
One of the most commonly used strategies in assisting incontinent patients is bladder retraining. This rather easily implemented strategy focuses on the establishment of habits. A time schedule of toileting is established for the patient; he is taken to the toilet and encouraged to empty his bladder on a specific schedule.
Two factors are of critical importance for the success of the program: (a) the establishment of an appropriate toileting schedule, and (b) the achievement, by the patient, of a sufficient fluid intake. Some authorities have used a schedule based on specific timed intervals, ie, toileting every two hours or every four hours. Rick16 suggests that the pattern be established around unvarying routines in the patient's life. Thus she suggests that the patient be taken to the toilet upon arising, before and after every meal, and before going to bed. Willington11 suggests that the schedule be based on the bladder capacity of the individual patient. If the patient's bladder normally becomes full every three and one half hours, he should be taken to the toilet every three hours. Willington suggests that the period from bedtime to the first incontinent episode at night, a time of mental and physical rest, be used as a basis for establishing a retraining schedule.
It is essential that the patient drink sufficient amounts of fluids during the retraining process. Maney17 suggests that the patient's intake be from 2,000 to 3,000 cc a day. It is, of course, essential that a variety of fluids be offered to the patient to reach this level. These may be offered on a set schedule, for example, every two hours from 6:00 A.M. to 8:00 P.M. Fluids are usually withheld past a certain time in the evening (such as 8:00 P.M. or 9:00 P.M.) to lessen the problem of nocturia.
Reports of effectiveness of bladder retraining in the elderly have been mixed. Chambers and Lyon18 reported good success with retraining based on a q 4 h training schedule used in conjunction with the administration of anticholinergic medication. Carpen- ter and Simon19 reported no decrease in incontinence in predominantly elderly, regressed, psychiatric patients using a q 2 h toileting schedule. Further research needs to be conducted in the area. '
In recent years, the technique of behavior therapy has been used with elderly incontinent clients. This technique attempts to shape the behavior of the patient by the use of positive reinforcement. Desired behavior, ie, urinary continence, is reinforced by the use of social or material rewards. Undesired behavior, ie, inconti- nence, is ignored; it is neither rewarded nor punished. Behavior which is rewarded should occur more often, thus continence should increase.
Implementation of a program of behavior therapy requires expertise in the area and thorough planning. Maney17 identifies five steps in the process: selection of subjects, definition of the problem, base line frequency collection, selection of reinforcement, contingency requirement, and evaluation.
Selection of reinforcers and consistency in applica- tion of reinforcement are keys to the success of the program. Such steips depend on individual assessment of each patient, and group work by all staff members caring for the patient. It is essential that reinforcerTbe^ rewarding to the patient; these must be determined on an individual basis. Reinforcement of behavior must be consistent; all staff members need to be included in the project in order to coordinate staff response to patient behavior.
The results of behavior therapy have been mixed. Some authorities feel that behavior therapy is not likely to benefit the elderly client.20 Carpenter and Simon19 found that behavior therapy, using social and material rewards, did reduce the incidence of incontinence in predominantly elderly regressed psychiatric patients while Grosicki21 found no decrease in incontinence using behavior therapy with neuropsychiatrie geriatric patients. Again, more research needs to be conducted in this area.
Evaluation of the effectiveness of the nursing plan is based upon stated goals and a method for measuring attainment of these goals. As continence, the ultimate goal, may not be attained for two or three months, it may be helpful to identify both the short- and long-term goals for the patient. During the early phase of the project, goals may be established which delineate minimal behaviors crucial to the training, ie: (a) The patient will void when placed on the toilet; and (b) The patient will drink a minimum of 2,000 cc/day. During the intermediate phase of the project, goals may be established which indicate progress to the overall goal, for example: (a) The patient is continent 25% of the time; or (b) The patient has 25% fewer "accidents" than during the base line period. The long-term goal demonstrates complete success: The patient is con- tinent of urine at all times.
In order to determine whether the patient has achieved the goal, it is necessary to establish some way in which to assess continence. An Objective way of doing this is to check the patient on an established schedule, for example, every hour during waking hours over a 24-hour period to determine whether or not he has been incontinent. This method needs to be used to establish a base line estimate of incontinent behavior before intervention is carried out. Once this has been accomplished, and a specific intervention has' been implemented, periodic checks need to be conducted during the course of treatment in order to determine progress. A schedule, ie, a 24-hour assessment once a week, needs to be established and implemented.
This paper has reviewed the nature of incontinence and has delineated nursing strategies which can be used in the care of the incontinent patient. Two types of incontinence have been identified: spurious and central incontinence. Five causes of central incontinence have been discussed: disorders of the pelvic diaphragm; disorders of the urethra; disorders of the bladder; disorders of neurological control; and the unstable bladder. The medical treatment of incontinence in- cludes physiotherapy, drug therapy, and surgery.
Nursing strategies must be based on accurate and thorough assessment. Two broad areas of assessment are identified: the assessment of physiological and environmental factors. Four nursing approaches to the problem of incontinence are discussed: alteration of causes of spurious incontinence, pelvic floor exercises, bladder retraining, and behavior therapy. Success of the plan is demonstrated by accurate evaluation.
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