Incontinence is a condition that causes a loss of dignity in persons of all ages. It is a distressing condition that affects a large number of young adults in the community. It becomes a most distressing condition for the elderly person (65 years or older) in the community and often results in admission to nursing homes. Since almost half of the institutionalized elderly are incontinent, incontinence contributes enormously to the health care costs of the aged.
Controlling incontinence may be within the scope of the nursing profession with the availability of several behavioral techniques. Behavioral approaches to incontinence have been researched in outpatients at the National Institute on Aging, Laboratory of Behavioral Sciences, and in United States nursing home residents. These are technologic developments that are ready to be tested further and possibly transferred into the practice of nursing, with the potential of saving health care dollars. This article will describe the magnitude of the problem, behavioral techniques that may control incontinence, and the implications for nursing.
An estimated 1.5 million noninstitutionalized adults have problems in controlling bowel movements or urination. The incidence of incontinence increases progressively with age, that is, 7.5 per 1000 have problems in the 45-64 age group; 17.3 per 1000 of those 65-74; and 46.7 per 1000 of those 75 years of age and over. Generally, women are more likely than men to have trouble with bowel or bladder control.1
Approximately 45% of all nursing home residents are incontinent. In the nursing home population, incontinence is compounded by other problems such as cognitive impairments or mobility problems. Of patients with bowel incontinence, 66% are mobility-limited; of those with bladder incontinence, 82% of them are mobility-limited.2
There have been no studies that document the cost of implementing a behavioral treatment program for incontinence. However, there have been several studies that have documented the costs of incontinence. One study estimated the costs of nursing labor and supplies for incontinent patients was $2.53 per day.3 A more recent study estimated that the annual costs of incontinence in nursing homes was at least $.5-1.5 billion dollars. In this same study, the range of costs for managing incontinence were $2.90-$5.11 minimum and $3.77-$lI.09 maximum per day. The yearly cost of incontinence for a person managed with a Foley catheter was about $2,888 and between $2,072-$4,532 per year for persons managed with disposable pads, reusable diapers, or disposable diapers.4
A study comparing the use of disposable pads to the use of Kylie bed sheets in patients with intractable incontinence demonstrated that the costs per day were reduced 39% with Kylie bed sheets. The average reduction in costs per patient per day was $1.25. Also important in this study was the 42% reduction in the frequency of bedding changes with the Kylie bed sheet which reduced nursing costs.5
One problem in determining the cost magnitude of incontinence is the different definitions of incontinence in each study. An immediate problem in determining the impact of these costs on nursing care is that these costs have been examined when nursing personnel managed incontinence and did not seek to control incontinence.
Definition of the Problem
Because many studies describe incontinence in different ways, it is important to understand the definitions of incontinence before describing the behavioral interventions that control it. Fecal incontinence is the inappropriate loss of stool that may result from abnormalities of the internal or external anal sphincter.6 Urinary incontinence is the inappropriate loss of urine resulting from a failure to emit normal responses as the bladder fills. Three types of urinary incontinence are common:
1) bladder hyperreflexia, in which bladder contractions are not inhibited;
2) stress incontinence in which the urethra is not effectively closed off during transient pressure rises; and
3) overflow incontinence, in which the bladder does not contract (atonic bladder) or the periurethral muscles do not relax during bladder contractions (bladder-sphincter dyssynergia).7
In addition, another type of incontinence is functional, that is, the inability or unwillingness of the person with a normal bladder and sphincter to reach the toilet in sufficient time.8
The evaluation of an incontinent person is a collaborative responsibility of the medical and nursing professions.9 The medical evaluation of the incontinent person involves a medical history and physical. The physical examination of the patient includes abdominal, pelvic, rectal, vaginal and neurologic assessment. The major medical diagnostic procedures for assessing urinary incontinence are urodynamic studies including cystometry and uroflowmetry (measuring bladder pressures during filling and emptying), Bonney's test (elevating the urethra to determine if leaking is prevented when the patient coughs with a full bladder), urinalysis including culture and sensitivity (to rule out bladder infection), and serum analysis of calcium, glucose and electrolytes. On occasion, the urodynamic testing extends to cystoscopy or intravenous pyelogram (IVP) or referrals of patients to gynecology, dermatology or pulmonary consultants.10 The major medical diagnostic procedure for assessing fecal incontinence is manometry. This study is used to evaluate the patients ability to perceive stool in the rectum, the competency of the anal sphincters, and the ability of the patient to respond appropriately to rectal distenti on.6
Nursing assessment of patient elimination patterns has been described by other authors. A nursing assessment of the patient with urinary incontinence has been described by Brink, 1980.11 In addition to a nursing history and physical examination, the nursing assessment also includes specific information about the psychosocial and environmental influences affecting a patient's voiding profile.
Because fecal and urinary incontinence are responsive to behavioral interventions, it is important for nurses to update assessment of elimination patterns with a behavioral analysis. Behavioral analysis is a technique which is designed to obtain specific information and objective behavioral data.12
The major components of a behavioral analysis are not within the scope of this paper. However, the general principles of such an analysis have been described by Engel, 1983. They include:
1) an assessment of the characteristics of the problem, e.g., the number of voids or bowel movements per day, and the number of accidents;
2) those factors that may preceed the incontinent event, e.g., specific events like sneezing, coughing, jumping that precipitate incontinence; and
3) the assessment of whether the incontinence reflects a social problem, interpersonal problem, or whether factors exist that reward incontinence, e.g. how the staff respond to the problem.
For nurses to utilize these measures to control incontinence, it will be necessary to develop behavioral assessment skills.
Of equal importance is the assessment of the person's perception of whether incontinence is a problem. If patients do not perceive of incontinence as a problem or even deny its presence, their motivation or desire to control it will be diminished. In addition, patients who have incontinence secondary to a cognitive disorder need to be identified. Included among them may be those diagnosed as having an affective disorder or dementia.
Managing Versus Controlling
Many long-term care nursing programs have described programs that manage incontinence where the outcome or attainable goal is to keep the patient dry. These programs manage and do not cure or control incontinence . A newborn infant's enuresis is managed by diapers and controlled when toilet training occurs. The bedpad is used to manage the elderly in wet beds. Bedpads are usually porous, absorb urine, and are moisture resistant so that the skin and bed remain dry. Bedpads have reduced the frequency of changing episodes, increased comfort due to decreased skin wetness, and reduced costs when compared to complete bed changes by nursing personnel but they do not control incontinence. Control and even cure of incontinence is often achievable through the use of behavioral measures.
The behavioral measures to control incontinence that are available to nursing are:
1) pelvic floor exercises,
2) habit training,
3) contingency management, and
Pelvic Floor Exercises - the exercises described by Kegel used to treat stress incontinence in women are employed. These Kegel exercises are appropriate for patients with intact cognitive function. Studies using these exercises report a decreased incidence of stress incontinence in women.13 Pelvic floor exercises have been used successfully to treat both young and elderly patients with stress incontinence.9,14,15
Pelvic floor muscle strengthening involves giving patients instructions to 1) tighten the ring of muscle around the vagina and/or the anus without tensing the muscles of the legs, buttocks or abdomen; and 2) repeatedly stop and start the flow of urine when voiding. The patient may use a perineometer which is a visual biofeedback device that registers the strength of contractions. This treatment usually takes 6-12 weeks for success.
Habit Training - an intervention for urinary incontinence that teaches persons to void at predetermined times in order to reduce the likelihood of accidents. Habit training utilizes symptom diaries of the times and circumstances of self-toileting and incontinent episodes. Diaries should also document the patient's reasons for the incontinence. These records are supplementary to temporal voiding schedules which is the treatment form of habit training.
Habit training is also called bladder training or bladder drill. By gradually increasing the time intervals between voiding, the training corrects the habit of frequent voiding and aims to improve voluntary control over the micturition reflex resulting in an increased bladder capacity. The rationale to this approach is that it requires the patient to resist the sensation of urgency, to postpone voiding, and to urinate within an appropriate time after drinking fluids rather than in response to an urge. These methods have been described in treating incontinent persons in nursing homes.16 The goal of treatment is to achieve two to four hour voiding schedules with no accidents.
During a 16 month trial of 172 persons living at home, a nursing team consisting of one team leader and two enrolled nurses (graduates of a two year program in England) resocialized 150 elderly persons. Eighty-nine individuals learned to control incontinence by habit training; 61 were managed by protective garments or by indwelling catheterization.16 Evaluations of habit training among inpatients in Summerfield Hospital demonstrated a 75% rate of success as early as 1975. 17
Habit training for overflow fecal incontinence secondary to stool retention consists of instructing the patient to attempt a bowel movement immediately after breakfast every day and to use an enema to stimulate a bowel movement if one does not occur for two consecutive days. Symptom diaries of bowel habits include times when bowel movements occur, episodes of fecal incontinence, and the situations in which they occur. In a study of community dwelling geriatric patients with fecal incontinence, five of 18 were treated solely with habit training. Two became continent during the first four weeks. Two achieved an average of 80% improvement, and one who was cognitively impaired did not improve.18
Habit training has no documented side effects. However, to provide optimal scheduling routines, this treatment requires more nursing time than conventional management methods. Habit training could also enhance patient dependence on nursing staff unless self-toileting is rewarded.
Contingency Management - this is a behavioral method using reinforcers to establish continent behaviors. Contingencies can be applied to the staff caring for the patient or to the incontinent person. Contingency management must include careful attention to staff or patients' rights and their consent. A recent controlled study using verbal and social approval to treat urinary incontinent residents of two nursing homes reported a 45% increase in the frequency of correct toileting. None of the patients in this study were independently ambulatory; 95% were diagnosed with organic brain syndrome or senile dementia. While the number of patients studied was small, the results indicated that an organized behavioral program can reduce incontinence in nursing home patients.19
Biofeedback alone and in combination with habit training and contingency management has been investigated at the National Institute on Aging, Laboratory of Behavioral Sciences for over 12 years. Biofeedback is another form of behavioral therapy which has been successful in the treatment of stress and urge urinary incontinence as well as fecal incontinence. The biofeedback procedure for urinary incontinence provides the patient with visual feedback of bladder pressure, abdominal pressure and external anal sphincter activity. The information is used to teach die patient to inhibit bladder contractions voluntarily and/or to control sphincter muscles while relaxing abdominal muscles. The feedback procedure for fecal incontinence provides the patient with visual feedback of internal and external anal sphincter activity.20 Descriptions of this procedure have been recently reported.6'20 Biofeedback has also been described as a nursing treatment to control bladdersphincter dyssynergia successfully.21
When biofeedback was used to treai elderly outpatients with stress or urge incontinence, the average improvement exceeded 75%. 22 In 13 older patients treated with biofeedback for fecal incontinence, four became continent and seven experienced more than 50% improvement. The cognitively impaired patients in this study were not treated with biofeedback but with habit training. One patient improved by 90% and the other showed no improvement.18
These biofeedback treatment programs have been tested with ambulatory older subjects who live in the community. A similar treatment program is proposed by the National Institute on Aging and the Health Care Financing Administration to determine the effects of behavioral interventions on institutionalized elderly who are incontinent.
The National Institute of Aging has produced a videotape cassette describing the behavioral treatment of urinary incontinence in older patients. In particular, this tape describes the use of biofeedback techniques for helping elderly patients master control over their bladder and sphincter muscles.
The tape, entitled: "Behavioral Treatment of Urinary Incontinence: Biofeedback of the Bladder and Sphincter Muscles," provides an overview of clinical techniques and behavioral principles used to treat urinary incontinence. It demonstrates the behavioral analysis of incontinence, the biofeedback procedure, and how to instruct the outpatient to practice skills in the home. The tape is particularly appropriate for nurses.*
We have described behavioral research technology that has been demonstrated to be valid and reliable for the control of urinary incontinence in geriatric persons. Most of the techniques described here were studied in elderly persons living in the community. While contingency management and habit training have also been demonstrated successfully in nursing home patients, further research is needed to define behavioral interventions that are effective for the incontinent with and without mobility and cognitive impairment in nursing homes.
Now that research has demonstrated the effectiveness of behavioral approaches to the problem of incontinence, the technology could be transferred into clinical practice. The technology transfer from research to practice can be accomplished most effectively through nursing schools, use of teaching tools like the videotape cassette, and training programs on the behavioral management of incontinence. These programs might enhance this learning process by adding trained specialists to their faculties. Since incontinence affects persons of all ages, information on behavioral management should not be restricted to training programs for geriatric nurse specialists. The problem of incontinence spans from childhood to old age, and it is a problem that nurses can be instrumental in solving. Nurses can become the primary care specialists in controlling incontinence and their interventions will save health care dollars.
Programs have been implemented in nursing homes with some success in the reduction in incontinent episodes, although further studies are needed. Nurses in nursing homes can be optimistic that incontinence is a problem that may be controlled by behavioral measures. In particular, the available behavioral techniques could move nursing from managing incontinence to controlling incontinence.
There still may remain persons whose incontinence may not be successfully treated by behavioral interventions. These persons may require training that will be more highly specialized or require alternative interventions. They may be more appropriately managed with bedpads, medications or devices. The goal of intervention, whether management or control, is to provide care and preserve dignity for the person.
Professional standards need to be implemented for the assessment of elimination patterns including valid and reliable behavioral nursing actions' to reach realistic outcome goals. These professional standards need to be reinforced by state and federal policies that recommend elimination assessments and behavioral interventions in caring for older incontinent persons in the community and in nursing homes.
The control of incontinence may be within the scope of nursing. Through Teaching Nursing Homes and research grants, the nursing profession can benefit from the programs in the National Institute on Aging, and many incontinent elderly can be optimistic about controlling incontinence with new advances in nursing care.
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