The Continence Clinic for older men and women at The VJniversity of Michigan is now in its second year of operation. Word of it has spread, resulting in numerous requests for information on how to establish such a clinic. In this article our experiences in developing and maintaining the Continence Clinic as well as data gathered during its first year will be presented. After providing background information, three phases of the clinic will be described: development, operation, and evaluation. Each phase has key points influencing the direction of the clinic.
Studies reveal that 10% to 14% of elderly people living in the community report episodes of urine loss or leakage.1-2 That finding represents a minimum of two million older people, probably a low estimate considering methodological variation and a propensity to underreport. Prevalence rates are much higher for those elderly living in long term care institutions with figures ranging from 38 to 76% incontinent of urine.3,4
Some personal and social consequences of losing urine control have been identified but remain difficult to measure. Common personal reactions are embarrassment, worry over future episodes, and fear of smelling or wetting on furniture, which can result in retreat from the company of others. Many individuals resign themselves to incontinence, believing it irreversible and inevitable with increasing age. They cope by special protective padding, severe fluid restrictions, and increasing withdrawal from social activity. Prolonged social isolation can lead to depression and if unchecked may result in an isolation-depression cycle.5
The incontinent individual is stigmatized; others may respond to him with discrediting, anger, or guilt.6 Urinary incontinence creates a heavy burden on care providers and may precipitate admission to long term care institutions. A survey of incontinence management in the home found laundry a critical problem both in terms of the actual washing necessary and the cost of extra sheets and clothing.7 In fact, the economics of incontinence are substantive. Estimating a minimum use of five facial tissues to make a pad per day at the lowest cost to community living, incontinent elderly creates on annual dollar sum of 8.6 million. Use of one low cost sanitary napkin per day for this group raises the annual expense to 43 million dollars. If the institutionalized incontinent use only one disposable blue pad per day, it constitutes a yearly cost of 22.8 million dollars.
Staff-Initially, the two nurse authors initiated the idea and original plans for the Continence Clinic. Their interest in aiding urine controi in older people stemmed from their clinical backgrounds, one who dealt with essentially home bound elderly, the other who worked in long term care institutional settings. They had collaborated to write a comprehensive review of the subject for a gerontological nursing textbook.8 Both are experienced in gerontological nursing and hold faculty positions at the University of Michigan School of Nursing where research into practice is supported and facilitated. In addition, both have experience in interdisciplinary team work, one through research, the other clinically, as a nurse practitioner.
The physician author is a board certified urologist with an appointment at the University's Medical School and a substantive record in urology research.9-10 A specialist in urodynamics, he had a Jong term interest in bladder control problems presented by his patients and extensive experience with patients having alf aspects of urine control difficulties.
Impetus - Various research planning sessions presented multiple opportunities to discuss a continence clinic for older people. Grant explorations within the University Hospital Department of Geriatric Medicine were led by its experienced Director, Dr. Ivan Duff, was aware of the significant problem of urinary incontinence amongst the old and supportive of interdisciplinary practice. He encouraged the group to pursue development of a continence clinic.
The National Institute on Aging organized a small invitational conference on urinary incontinence in the elderly during the rail of 1980. Dr. Diokno and Dr. Wells were invited. Preparatory to attending the Washington meeting the two met and discussed the upcoming project and their research interests with enthusiasm. Subsequent meetings allowed Ms. Brink to participate as a team member to aid the development of the research proposal.
During this time the nurses were invited to present a program on urine control to an active group of local senior citizens. Although the team expected only IO to 15 attendees, they were amazed to see the meeting attended by more than 75 older people. A very interactive and interested audience, the senior citizens asked many questions which indicated that urine control was a common area of concern to them. Organizers of their group later reported that the urine control session had been the most popular of the year.
Setting - Ann Arbor is a city with a population of 107,000 in southeastern Michigan, about sixty miles from Detroit. It is the home of the University of Michigan, officially committed to the study of aging since the founding of the Institute of Gerontology in 1965.
In 1977 a specialized clinic for the ambulatory elderly (aged sixty and over), the Turner Clinic, began operating under the University Hospital's Internal Medicine, Department of Geriatrics. Directed by Dr. Ivan Duff, the clinic is highly respected and well known to the community. Situated apart from the main hospital area, the Turner Clinic is accessible to older people by bus and provides close, adequate metered parking space for those with cars. It is a modern unit with six examining rooms; a meeting room; and interview, laboratory, and staff work areas. The staff, composed of receptionists, nurses, physicians, and social workers are experienced and skilled in working with older people. Specialty services such as psychiatry and nutrition consultation are available, an active health education and counseling service provides many programs, and an outreach clinic structure operates in three local senior high rise buildings. Our continence clinic would be located here.
Planning - An early philosophic agreement among the authors was to focus on attainment rather than loss - positive rather than negative concepts. As a result, continence was selected for the clinic title rather than incontinence. A further advantage to this choice was a degree of subtleness provided by an uncommon term, hopefully reducing embarrassment for clients.
A few team meetings at the proposed clinic site worked through the collaboration details between Internal Medicine's Geriatric Department, Urology, and Nursing. The Continence Clinic was to be a specialty service outreach of the Urology Department. The client fee was equal to costs at the standard hospital outpatient clinic, billed through the urology service and covered fully or in part by health insurance programs- Effort was made to understand the Turner Clinic operation, e.g. , appointment system, recordkeeping, staffing patterns, etc., to avoid creating any special Burdens on the existing establishment.
The purpose of the clinic was broadly identified as helping older people with urine control problems. Its title. Continence, connoted a breadth of urologie difficulties and required that comprehensive, specialty focused evaluation be available.
The Turner Clinic setting provided the equipment necessary to analyze urine on site, i.e., centrifuge, microscope, test tubes. Specimens could be sent to the hospital laboratory for further evaluation, such as culture and sensitivity. If evaluation beyond these basics was required, the main hospital urologie department's full range of diagnostic services would be utilized.
The Clinic's services would include urological evaluation and treatment to resolve or reduce urine control difficulties. Where treatment was not effective or possible, help in management of urine wetting would be provided through product information, appliance or catheter guidance, and a variety of individualized options determined through counseling. The Continence team perceived their role in the individual's health care as cooperative with the primary provider. Thus, with patient consent, diagnostic evaluations would be sent to the client's personal physician with whom treatment and progress would be discussed as appropriate.
It was agreed that patients could refer themselves or be referred through a physician, nurse, other health provider, or family member. However, during the planning stages, the main Turner Clinic had a number of potential Continence Clinic referrals. It seemed sensible to start slowly with this patient source, allowing the team a period to practice together before increasing the clinic load. Analysis of the team's busy schedules revealed only one half day a week for collaborative practice. This time frame was arranged in conjunction with available space at the site of the Continence Clinic.
CONTINENCE CLINIC PATIENT CHARACTERISTICS: FIRST YEAR
CONTINENCE CLINIC PATIENT INITIAL DISPOSITION: FIRST YEAR
The Continence Clinic went into operation in October, 1981 with three referred Turner Clinic patients scheduleld. Since all the patients were new to the Continence Clinic and the team was learning to work together only two or three appointments were arranged per clinic session. During the early months, roles were defined and redefi ned . The team members were experienced in their own domains, respected each other, and had conceptually worked together before the clinic opened. These factors contributed to the interpersonal comfort of this period.
From the start, Dr. Diokno believed that managment of the clinic was the nurses' role. Initially, the whole team saw each patient with leading the history-gathering and examination appropriate to their individual ability, te, one as the nurse practitioner, the other as clinical nurse specialist. Dr. Diokno conducted further patient questioning and demonstration of new or different techniques. Later, the nurses each saw patients alone, made an evaluation, and then were joined by the team for confirmation through repetition of selected history or physical examination findings.
Currently, one to three new patients and three to four follow-up patients were seen each week at the Continence Clinic. Dr. Diokno spent a limited time at the session validating findings, discussing treatment plans, and consulting on new or complex cases. He was available by phone for the remaining session time and throughout the week if problems arose.
Midway through the first year we decided to develop a Continence Clinic brochure and appointment card. The brochure describes the services available and was sent with an explanatory letter to local physicians, visiting nurse/public health services, senior citizen housing units and social groups. Description of the clinic service was published in the local senior citizen newsletter. These actions and 'word of mouth' kept the clinic schedule booked several weeks ahead.
In March, 1981, the Continence Clinic team was pleased to learn that the National Institute on Aging had funded their research project. Effort then expanded to include clinic sessions specifically for research subjects. Additional staff were added in the persons of a part time secretary and a full time research assistant. The Continence Clinic still operates as described and additionally provides two hours per week outreach service to the Turner Geriatric Senior High Rise Clinics.
In its first year, the half-day clinic session was held on only thirty-eight weeks due to prior team commitments, vacations, and holidays. Forty-seven new patients were seen with thirtyseven return visits. The entry of twelve patients into the research project during this time decreased the true return rate.
The characteristics of patients seen at the clinic are shown in Table I. Females out numbered males in almost a 5:1 ratio. The majority of both sexes were in their seventies, males slightly older than females. (77.9 years to 75.8 years respectively) Only three patients were in institutional or supervised care; these were exclusively older males (age x 82 years). As had been planned, the Turner Geriatric physicians were the primary source of referral. The majority (94%) of patients major complaint was uncontrolled urine leakage; most prominent was urine loss associated with urgency. The actual frequency of stress urinary incontinence was greater than that initially presented as a problem. Apparently some women considered stress urine loss normal or of such long duration in their experience that it appeared normal to them. Patients with dementia were unable to give histories and their care providers could only partially supply relevant details. Four patients presented with non-specific leakage complaints, i.e., the urine loss seemed constant or not related to any pattern .
Initial patient disposition is reflected in Table II. Medications were a common treatment, most typically anticholinergic drugs. Further urologie evaluation was requested for twenty-one patients; twelve of these were enrolled into the research program which required a set of urodynamic testing. The remaining patients had a variety of urologie tests, commonly cystometric, cystoscopy and Intravenous Pylogram.
Referral to other clinics included gynecology and dermatology, as well as other specialty services. Referral back to the Turner Geriatric group (not included in this figure) was an informal process which arose as the Continence Clinic team discovered unstable or new medical conditions. The exercise program most frequently taught was the pelvic floor or kegal training. Wetting management advice in terms of fluid intake, voiding schedules, and helpful products was provided for all patients but was the sole action of only three.
Professional Relationships - The collaborative, interdisciplinary nature of the Continence Clinic fostered positive Professional relationships both within the team and the mult idiscipline Turner Geriatric Clinic setting. Interaction with physicians outside the University was predominately informational but resulted in several referrals. Evidence of a nurse referral network began to emerge. Three of the eight nurse contacts were Public Health Nursing sources.
Contact was made with all manufaturers of products suitable for urine wetting management. Product samples and descriptive brochures were acquired by any available means. Product mail order information was sought, as well as identification of local health care store suppliers who would stock such items. The clinic team found that access to a range of products was most helpful for the variety of patients seen at the clinic. Thus, no one product was advocated in general over another and advice to patients was individualized according to their needs.
Educational Efforts - The Continence Clinic team, individually or in pairs, provided educational programs about urine control in old age to a variety of professional and lay audiencesat a rate of about two programs per month during the first year. In addition, correspondence and telephone contacts often requested consultation regarding evaluation and treatment of urinary incontinence as well as wetting management information. It became evident that education/consultative requests required team availability not previously envisioned. Fortunately, research finding provided some time release, a portion of which could be justified in such activity to elicit study subjects. Increased publication of the clinic process, materials, findings, and research may alleviate some of the educational requests.
Immediate and on-going educational contributions also derive from the Continence Clinic team's University of Michigan faculty roles; all teach in their respective schools. Increasingly, students have identified problems in urine control for research projects.
- 1. Sullivan J. Seigle H, Wooldridge P. Wells T, el al.: Health Maintenance Strategies for the Well Eiderlv. D.H.E.W. Grant No. 116-0743209, Unpublished Data, 1979.
- 2. Yarnell, JW. St. Léger AS: The prevalence, severity and factors associated with urinary incontinence in a random sample of the elderly. Age and Aging 1979; 8:81-85.
- 3. JewettMA, FernieGR, Halliday. RJ, et al: Urinary dysfunction in a geriatric long-term care population: Prevalence and patterns. J Amer Geriatr Soc 1981; 29:211-214.
- 4. Wells T: Problems in Geriatric Nursing Care. New York. Churchill Livingstone, 1980.
- 5. Brink C; Urinary continence/incontinence; Assessing the problem. Geriatric Nursing 1980; 1:241-245.
- 6. Wells T: Social Relevance of Incontinence in the Elderly. Unpublished paper. International Congress of Gerontology, Hamburg. Germany. 1981.
- 7. Dobson P: Management of Incontinence in the Home: A Survey. London, Disabled Living Foundation, 1974.
- 8. Wells T, Brink C: Urinary continence: Assessment and management. In: Burnside, led: Nursing and the Aged. New York, McGraw Hill Book Company, 1981.
- 9. Lapides J, Diokno AC: Physiology of micturition. In: Buchsbaum, HJ, Schmidt, JD eds: Gynecologic and Obstetric Urology. Philadelphia, WB Saunders, 1978.
- 10. Diokno AC, Incontinence in the elderly. In: Calkins, E ed. Geriatric Medicine. Philadelphia, WB Saunders, in progress.
- 11 . Wells T (PI), Brink C (Co-I), Diokno, A (Co-1): Nursing Interventions: Urine Control in Older Women. National Institute on Aging, Grant No. 1 ROI AG03542, 1982.
CONTINENCE CLINIC PATIENT CHARACTERISTICS: FIRST YEAR
CONTINENCE CLINIC PATIENT INITIAL DISPOSITION: FIRST YEAR