Journal of Gerontological Nursing

MANAGING URINARY INCONTINENCE with Self-Care Practices

Anita M Thomas, RN, MN; Janice M Morse, RN, PhD(Anthro), PhD(Nurs)

Abstract

The excretion of body waste is considered a private human function; therefore, public conversation about body excretion is generally taboo.1 This social norm is reflected in the fact that health-care professionals use the term "passing water" when asking a patient about micturition. Although incontinence is a serious and sensitive issue, the problem of incontinence has historically been neglected by health-care professionals. Although there have been major advances in the diagnosis and treatment of urinary incontinence, the current fallacy that incontinence is incurable in the elderly has changed very little over the last 400 years.2 Furthermore, Smith suggests that an apathetic attitude toward investigation and treatment of incontinence in the elderly reflects a lack of knowledge and misunderstanding among health-care professionals.3

Review of the research literature regarding the management of urinary incontinence in the elderly reveals contradictory positions. Supporters of one position feel that many incontinent individuals do not seek professional assistance and may even deny the existence of a problem. Because elderly clients have long accepted incontinence as an unpleasant but inevitable consequence of old age,4 they are not inclined to report the problem to health-care professionals. Consequently, the prevalence of incontinence in the elderly remains an unrecognized community health problem.5,8 Many incontinent elderly attempt to cope independently by using pads, restricting fluids, and withdrawing from social gatherings.9

A contrary view posited by some recent researchers disputes the fact that incontinence is a devastating condition that restricts the lifestyle of the older individual. Proponents of this position believe that many older persons manage to control their bladder problems without assistance from professionals, and, in fact, the actual problem surrounding the issue of incontinence is the attitude of health-care providers.10,11 These opposing viewpoints clearly indicate that there is a notable lack of knowledge about the older adult's day-to-day experience with urinary incontinence. A better understanding of their experience is critical, especially for nurses and other health professionals. There is a need to be receptive to the concerns of incontinent elderly persons and to provide pragmatic assistance in implementing strategies to cope with the problem.

Table

RESULTS

The social ramifications of incontinence were explored by asking respondents whether they had discussed the "problem" with any other person and whether they felt inhibited to undertake any social activities because of their incontinence. Most of the respondents (70%) had told someone about their problem with bladder control, usually a close friend or a relative. A few informants elaborated on the importance of having someone, such as a sister, with whom to share the problem. In contrast, all of the men had confided in either a family member or a friend; they approached the topic in a "matter of fact" manner. However, nine women (15%) had told no one about their incontinence problem: not family, a friend, or health-care professional. A large majority of the informants in this study considered the topic of incontinence to be taboo in social conversation.

Fifty respondents (83%) reported that they did not significantly limit or reduce their activity outside of the home. Ten people reported mobility problems, which ranged from arthritis, cardiac conditions, multiple sclerosis, and paraplegia. Eight of these 10 people denied that incontinence contributed to their withdrawal from social activities. Most of the study subjects perceived incontinence as something that one just "got used to" and "learned how to manage." The most commonly stated words to describe incontinence were annoyance and nuisance (Table 1). Others described incontinence as something one "put up with" and accepted. One man, who was alert, active, and happy with his life, said, "You see, Fm so lucky in some ways. I'm 86…

The excretion of body waste is considered a private human function; therefore, public conversation about body excretion is generally taboo.1 This social norm is reflected in the fact that health-care professionals use the term "passing water" when asking a patient about micturition. Although incontinence is a serious and sensitive issue, the problem of incontinence has historically been neglected by health-care professionals. Although there have been major advances in the diagnosis and treatment of urinary incontinence, the current fallacy that incontinence is incurable in the elderly has changed very little over the last 400 years.2 Furthermore, Smith suggests that an apathetic attitude toward investigation and treatment of incontinence in the elderly reflects a lack of knowledge and misunderstanding among health-care professionals.3

Review of the research literature regarding the management of urinary incontinence in the elderly reveals contradictory positions. Supporters of one position feel that many incontinent individuals do not seek professional assistance and may even deny the existence of a problem. Because elderly clients have long accepted incontinence as an unpleasant but inevitable consequence of old age,4 they are not inclined to report the problem to health-care professionals. Consequently, the prevalence of incontinence in the elderly remains an unrecognized community health problem.5,8 Many incontinent elderly attempt to cope independently by using pads, restricting fluids, and withdrawing from social gatherings.9

A contrary view posited by some recent researchers disputes the fact that incontinence is a devastating condition that restricts the lifestyle of the older individual. Proponents of this position believe that many older persons manage to control their bladder problems without assistance from professionals, and, in fact, the actual problem surrounding the issue of incontinence is the attitude of health-care providers.10,11 These opposing viewpoints clearly indicate that there is a notable lack of knowledge about the older adult's day-to-day experience with urinary incontinence. A better understanding of their experience is critical, especially for nurses and other health professionals. There is a need to be receptive to the concerns of incontinent elderly persons and to provide pragmatic assistance in implementing strategies to cope with the problem.

Table

TABLE 1MAJORRESPONSESTO URINARY INCONTINENCE REPORTED BY AGE OF RESPONDENTS

TABLE 1

MAJORRESPONSESTO URINARY INCONTINENCE REPORTED BY AGE OF RESPONDENTS

LITERATURE REVIEW

From the literature, it is difficult to discover the prevalence of incontinence in the elderly. Although previous researchers have conducted surveys using select groups of subjects, the current practice of using a variety of definitions to describe incontinence makes comparison of these studies difficult.12,13 Traditionally, incontinence has been found to increase with age, and women have been more likely than men to report incontinence. Estimates of incontinence in the elderly range from 7% in men to 18% in women.3 Even though urinary control problems appear to be common, they vary greatly in their degree of severity.

Although urinary incontinence is relatively common among older adults, investigation into the problem is hampered by the perseverance of an attitude of avoidance and denial among health-care professionals. Nurses have traditionally accepted incontinence in the elderly as a "normal" occurrence.14 Nurses simply "cope" with the problem without understanding the client's experience or the possible causes or treatments of incontinence.15 Breakwell and Walker report that nursing staff in a community health-care agency were aware of fewer than half of the cases of elderly incontinence found by the researchers in the same community. 16 In addition, social workers were reported to have less sympathy for the incontinent elderly as compared with those elderly who were confused or who had problems with ambulation and mobility.11 Combined with inappropriate professional attitudes, this lack of awareness may make elderly clients reluctant to reveal bladder control problems and, consequently, may inhibit the provision of appropriate care for the elderly.

Currently, little is known about the experience of bladder control problems from the client's perspective. Yu found some evidence to support the notion that incontinence can be stressful for elderly persons residing hi a long-term care facility.17 Unfortunately, the sample for that study was small, and a comparison group of continent adults was not included; therefore, the stress attributed to incontinence could have been related to confounding factors. On the other hand, Simons found no difference in self-esteem scores of elderly women who were incontinent as compared with a group of women who were continent.18 Simons also found that many of these incontinent elderly women had not discussed the problem with a health-care professional because they viewed incontinence as an inevitable aspect of the aging process.18 Because these elderly women have resigned themselves to incontinence, the hypothesis that incontinence is a "devastating experience" was not supported by this study.

Evidence that the incontinent elderly are able to cope with incontinence and enjoy a fulfilling and independent Ufe has been observed among older residents living in the community. A reduced level of participation in social activities by the incontinent elderly may be due to the presence of other health problems, and it cannot be attributed solely to the assumption that incontinence is a debilitating problem.12

Despite the fact that many elderly people manage their incontinence alone, much of the research literature regarding incontinence emphasizes the role of health-care professionals in the assessment, diagnosis, treatment, and management of incontinence. The purpose of this study was to examine the perceptions of elderly persons who experience urinary incontinence. The research question addressed was "What is the day-to-day experience of incontinence for the older individual who lives independently in the community?"

METHOD

The aim of this research was to elicit detailed, in-depth descriptions of the experience of urinary incontinence. Because the topic has virtually been ignored by previous health-care researchers, a qualitative method of data collection and analysis was selected for the research design. Semi-structured questions permitted informants to respond candidly. Rather than fitting the data into a predetermined extant theoretical framework, an inductive method of data analysis ensured discovery of emergent categories that truly represented the phenomena of urinary incontinence as it was experienced by the elderly study participants. The method allowed the researcher to ask all the respondents similar questions so that all responses could be coded, compared, and analyzed using nomparametric statistics.19 Thus, a descriptive profile of the experience of incontinence in the elderly was inductively obtained providing a better understanding of the client's point of view.

Sample

The sample consisted of 60 individuals over 50 years of age who were living in the community in their own home, apartment, or lodge. Individuals volunteered to participate in the study by responding to advertisements placed in a community newspaper; in a newsletter for senior citizens; in handouts available for senior citizens at retirement centers, residences, and lodges; and on posters displayed in public health clinics. The age range of the study participants was from 51 to 88 years, with a mean age of 70.6 years. Most study participants were women; only seven informants were men.

All of the participants in this study described their problems with bladder control in terms of being unable to prevent the loss of urine. Most (63%) spoke of a sudden and strong urge to void, many (40%) lost from a "few drops" to a "pool of urine" when laughing or coughing, and others also complained of "a dribble" during activity. Eight subjects said they had "no control over bladder function."

Data Collection

A semi-structured interview schedule was developed and used to guide discussions with the participant during tape-recorded telephone interviews. This interview schedule was reviewed and critiqued by a nurse-researcher and pretested for clarity and readability by two elderly individuals known to experience incontinence. The open-ended questions covered areas such as the day-to-day experience of incontinence, self-care practices used to manage and control incontinence, professional advice and treatments received, and the impact of urinary incontinence on the individual's social activities and psychological well-being.

Informed consent was obtained from each informant after the researcher verbally described the study over the telephone. Initially, the verbal consent was tape-recorded at the beginning of the first interview tape; later, the consent was dubbed onto a separate tape kept specifically for this purpose. To protect anonymity, the consent was then erased from the original interview tape prior to transcribing. Conducting the interviews over the telephone maximized anonymity and enhanced the informants' ability to disclose the intimate details of their personal experience. Another advantage of telephone interviews was convenience for the respondents; they were interviewed in their own homes and at a time of their choice.

Table

TABLE 2CONTINGENCY TABLE: MAJOR FEELINGS ABOUT URINARY INCONTINENCE AND REPORTED DISCUSSION WITH HEALTHCARE PROFESSIONALS*

TABLE 2

CONTINGENCY TABLE: MAJOR FEELINGS ABOUT URINARY INCONTINENCE AND REPORTED DISCUSSION WITH HEALTHCARE PROFESSIONALS*

Data Analysis

The tape-recorded interviews were transcribed verbatim; then, each question was content analyzed and categories were identified according to common responses. Responses within each category were summarized in frequency tables. Grouping the data into 10-year spans proved useful for comparing the relationships between the frequency of different responses by age group. Hypotheses were developed in relation to selected variables, and the associations between these variables were tested using chi-square analysis.

Limitations

The non-random selection of the sample limited participants to those who were willing to initiate contact with the researchers. It is probable that the perspectives of those who were too embarrassed or unable to participate and phone the researcher due to communication difficulties or cognition were not included in the study. Furthermore, the perspectives of those who were coping and therefore did not view incontinence as a "problem" were also not included. The experiences of these groups should be included in future studies. Despite the fact that it was not possible to interview informants representative of all possible aspects of the incontinence experience, the various methods of advertising for volunteers provided an opportunity for a large number of seniors to participate in this study. Although the results of the study are not able to be generalized to the target population of all incontinent elderly, the experiences of a large number of seniors with incontinence problems are described and the implications for practice presented.

Table

TABLE 3REPORTED SELF-CARE PRACTICES BY AGE OF RESPONDENTS

TABLE 3

REPORTED SELF-CARE PRACTICES BY AGE OF RESPONDENTS

RESULTS

The social ramifications of incontinence were explored by asking respondents whether they had discussed the "problem" with any other person and whether they felt inhibited to undertake any social activities because of their incontinence. Most of the respondents (70%) had told someone about their problem with bladder control, usually a close friend or a relative. A few informants elaborated on the importance of having someone, such as a sister, with whom to share the problem. In contrast, all of the men had confided in either a family member or a friend; they approached the topic in a "matter of fact" manner. However, nine women (15%) had told no one about their incontinence problem: not family, a friend, or health-care professional. A large majority of the informants in this study considered the topic of incontinence to be taboo in social conversation.

Fifty respondents (83%) reported that they did not significantly limit or reduce their activity outside of the home. Ten people reported mobility problems, which ranged from arthritis, cardiac conditions, multiple sclerosis, and paraplegia. Eight of these 10 people denied that incontinence contributed to their withdrawal from social activities. Most of the study subjects perceived incontinence as something that one just "got used to" and "learned how to manage." The most commonly stated words to describe incontinence were annoyance and nuisance (Table 1). Others described incontinence as something one "put up with" and accepted. One man, who was alert, active, and happy with his life, said, "You see, Fm so lucky in some ways. I'm 86 years old. I tell people, well, I can walk a little bit, I can hear a little bit, I can see a little bit, and I'm so lucky that I can't complain about this little bladder problem, as long as I've got it under decent control."

However, seven participants ( 1 1 .6%) did feel restricted in their daily activities because of incontinence. Five women and two men were troubled by their problem and expressed feelings of disgust or distress. They found that incontinence interfered with daily life and was difficult to control. Others expressed feeling embarrassed because of odor or leakage. These people paid careful attention to hygiene and changed wet pads or clothes immediately after they became soiled.

In general, the majority of the informants perceived incontinence from a passive perspective. Incontinence was described as unpleasant and troublesome but manageable. Incontinence was considered a constant worry, and many informants took care to void before leaving home and planned trips in relation to the availability of a toilet.

Most respondents (75%) had sought medical advice regarding their bladder control problem. Treatment recommendations prescribed were either surgery or medication. Three women were told that "nothing could be done" to control their incontinence. More than 20% of the respondents were unable to recall any medical advice; for some, their physician knew about the problem but has "said nothing"; and others could not remember their physicians' advice. The respondents who had not reported the bladder problem to their physician (27%) believed that their incontinence was "too insignificant" to discuss.

Only 17 respondents had discussed incontinence with a nurse, and two had talked to a physiotherapist. This contact was coincidental rather than planned. Ten of these people discussed the need for urinary incontinence garments with a nurse because they were aware that free supplies could be obtained from the Alberta Aids to Daily Living, Extended Health Benefits program. Only three of the six informants who reported speaking with a nurse could recall being given any advice or teaching. Two of the most commonly reported recommendations from nurses were allowing adequate time to empty the bladder and restricting fluid intake in the evening.

The informants had two reasons for not seeking a nurse to discuss their incontinence: the belief that only a physician should manage health concerns and a perception that respondents lacked access to a nurse. Two respondents said that "there is no nurse in the family." Other informants, who had regular contact with a community health nurse but did not discuss their incontinence, perceived that management of the problem was not an aspect of the nurse's role. Expressed reluctance to inform health-care professionals about urinary incontinence led to the hypothesis that a relationship may exist between participants' feelings about incontinence and their unwillingness to report the symptoms. Chisquare analysis to examine the potential relationship between these variables was conducted, but the analysis did not reveal an association (Table 2).

Reported self-care practices included the use of various types of pads, selfimposed fluid restrictions, and frequent or regular toileting patterns (Table 3). Sanitary pads and commercial incontinence garments were the most common types of padding even though the commercial garments were generally described as uncomfortable, hot, bulky, and "like wearing a diaper." Several respondents reported using a combination of sanitary pads, commercial garments, or homemade pads. Despite the fact that pads would have been provided for free if the senior had applied for this benefit, the cost of the pad was a factor for some people.

Another commonly used strategy was frequent or regular toileting. One women reported an extreme example of this, stating she voided every half hour during the day. More than half of the subjects did not vary their fluid intake because of incontinence, although seven reported drinking more fluids, and 12 indicated that they had "cut down." Five people reported practicing pelvic floor exercises, which they learned from a nurse, physiotherapist, physician, or from a newspaper medical column. Also, two informants described unusual strategies for dealing with incontinence: one woman drank small amounts of pickle juice, believing it to be a bladder "astringent," and one man believed that hot baths and warm clothing prevented "chilling of the kidneys," which he thought caused his incontinence.

DISCUSSION

The participants in the study outlined a range of problems regarding incontinence. Most informants managed their problem without professional help by using innovative strategies to prevent or absorb urine loss. Strategies were learned on a trial and error basis. These people manipulated their fluid intake, made sure of the location of toilets, and were meticulous about their hygiene. Respondents tended to organize their daily activities around the problem of urine loss, viewing it as a routine similar to "dressing for the weather." The possibility of incontinence was always "in mind," but many respondents were determined that it would not keep them at home.

The respondents in this study reinforced the views of Wells14 and Mitteness10 that professionals do little to assess or treat the symptoms of incontinence. Few respondents had discussed incontinence with a nurse, and for those who had, there was little evidence that any kind of assessment or discussion of strategies had taken place other than the ordering of incontinence supplies. In general, nurses were not seen as being available for consultation. One solution to this problem might be an incontinence clinic staffed by nurse clinicians. Such a facility would provide a reliable referral source and enhance the ability of professional nurses to respond appropriately to clients who have incontinence problems.

In dealing with incontinence, the informants in this study used a variety of products. Sanitary pads were frequently used by women. Both men and women used the commercial adult briefs and pads, but these were perceived as "diapers" and as being clumsy, uncomfortable, and expensive. Nothing was completely satisfactory. This study revealed new information about the needs of mobile adults, and it points out the necessity for manufacturers to address these needs.

The findings in this study resemble the findings of Mitteness10 and Falconer20 regarding other self-care practices, although fewer respondents in this study (20%) reduced their fluid intake and 18% used frequent toileting. These differences may be attributed to the nature of the study sample. It is recommended that a larger study on a randomly selected sample be undertaken in the future.

Future research samples should include elderly people who are unable to manage their incontinence independently. Furthermore, investigation hito the attitudes of health-care professionals regarding incontinence would clarify whether caregivers actually enhance or hinder an elderly person's ability to cope with bladder control problems. Understanding the client's perspective will enable health-care professionals to help clients manage their incontinence independently and confidently.

REFERENCES

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  • 18. Simons J. Self-Concept in Elderly Females: The Impact of Urinary Incontinence. Tucson, Az: University of Arizona; 1983. Thesis.
  • 19. Field P, Morse J. Nursing Research: Application of Qualitative Approaches. London: Croom Helm; 1985.
  • 20. falconer P. The Effect of Aging on the Time Between the Urge to Void and the Need to Void in Elderly, Self-Ambulant, Continent, Institutionalized Women. Rochester, NY: University of Rochester; 1979. Thesis.

TABLE 1

MAJORRESPONSESTO URINARY INCONTINENCE REPORTED BY AGE OF RESPONDENTS

TABLE 2

CONTINGENCY TABLE: MAJOR FEELINGS ABOUT URINARY INCONTINENCE AND REPORTED DISCUSSION WITH HEALTHCARE PROFESSIONALS*

TABLE 3

REPORTED SELF-CARE PRACTICES BY AGE OF RESPONDENTS

10.3928/0098-9134-19910601-05

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