Urinary incontinence is known to be a chronic problem for many older adults. In fact, the prevalence of urinary incontinence in older communitydwelling women has been reported as high as 35% to 41% (Brown et al., 1996; Nygaard & Lemke, 1996). To determine if urinary incontinence is a problem, accurate assessment of an individual's fluid intake and urinary elimination pattern is essential. One tool to assist in describing this pattern is a bladder diary.
Bladder diaries are similar to intake and output records that nurses have used for many years, but diaries can be self-adrninistered by clients. Bladder diaries are useful not only in assessment but also in evaluation of the effectiveness of various modalities to promote urinary continence. The focus of this article is on bladder diaries and how they were used in a research study with residents of retirement settings.
Bladder diaries evolved from intake and output records traditionally used only by health care personnel within institutional settings. Most of these records simply involved handwritten entries of measured or estimated amounts of fluid consumed and urine eliminated. One variation in this approach was a chart, developed by Clay (1978), on which nurses recorded voluntary voidings and incontinent episodes of patients, using colored dots. The dots became a graphic representation of the patient's voiding pattern and were used as a basis for implementing interventions for urinary incontinence.
Nursing assistants, as well as nurses, were involved in using the Incontinence Monitoring Record (IMR) within nursing home settings (Ouslander, Urman, & Uman, 1986). This record included information not only on voluntary voidings and bladder leakage episodes but also on bowel incontinent episodes. There were two versions of the IMR, one which contained black and white symbols for recording events and another having colored circles for event documentation. Results showed that recordings on the IMR were made more frequendy with the colored circles version of the record. The authors concluded that the IMR was useful in assessment and evaluation of incontinence, plus it provided an opportunity for nursing assistants to contribute in a more meaningful way to the care of incontinent patients. Additional studies using staff-completed voiding records have been reported in the literature (Hughes & Anderson, 1992; Miller, 1990).
Still within the institutional setting, but moving beyond the necessity of staff involvement in data recording, Autry, Lauzon, and Holliday (1984) allowed hospitalized patients, who were capable of doing so, to apply their own colored dots on a chart, according to the type of urinary elimination episode that occurred. The information from this record was used as a screening tool, for preoperative and postoperative assessment, and as an evaluation of the effectiveness of various nursing and medical interventions on voiding.
Expanding the focus beyond institutions, to the health needs of independently living older adults in the community, studies were reported using forms and procedures that could be completed by clients themselves. Most of these studies involved female clients. However, Robb (1985) focused on men and urinary incontinence. For this study, participants recorded voluntary voidings, incontinent episodes, and fluid intake 24 hours a day for 7 days. Because this was one of the first studies reporting fluid intake and urinary output data collected by clients themselves, it was notable that the majority of participants were able to maintain accurate and complete records.
The phrase "urinary diary" was used by Wyman, Choi, Harkins, Wilson, and Fand (1988) in testing the reliability of urinary data documentation by women with incontinence. Fifty community-dwelling women, age 55 and older, recorded data in urinary diaries for 2 weeks. Diurnal and nocturnal micturition frequency and number of incontinent episodes were highly reproducible from the first week to the second week. Therefore, data need only be collected for a 7-day period. Additionally, Wyman et al. (1988) concluded that diaries offered the potential for reduction of recall error of clients, which can occur in retrospective interviews, and the diaries provided valuable assessment data from directly within the client's own environment under actual daily life conditions. In a separate, subsequent study, fluid intake diaries were completed by the female subjects in addition to the week-long urinary diaries (Wyman, Elswick, Wilson, & Fand, 1991).
Although recording of diary data by hand for a week's time was manageable by community-dwelling clients, several alternative approaches have been tested and found to be successful. One approach is a shortened time period of actual data collection. Lentz and Stanton (1992) compared urinary diary data collected for 3 days with data collected for 7 days. They concluded that 3-day diaries involving a weekend are as accurate as 7-day diaries for assessing intake and voiding patterns in community-dwelling women.
Another alternative approach is a different method of data recording. A computerized voiding diary was developed and compared to the standard written diary (Rabin, McNett, & Badlani, 1993, 1996). Two groups of women, one with voiding problems and one without, completed both forms of the voiding diary. A significant number of women in both groups preferred the computerized version of the diary. Rabin et al. (1993, 1996) also stated there was heightened quality of the information obtained in the computerized diary compared to the written diary.
Although voiding or bladder diaries have evolved over the years, research studies have shown them to be used effectively with older people. Written bladder diaries, including information on fluid intake, were used to describe voiding patterns in a study involving residents of retirement settings.
A descriptive, correlational study was conducted to elicit information on fluid intake and urinary variables in a sample of older adults. This report focuses on the descriptive data obtained with the bladder diaries. All participants lived in retirement settings.
A retirement setting, for the purpose of this study, was defined as a circumscribed community in which a majority of the residents were age 55 or older and capable of self -care. A convenience sample of 51 participants completed bladder diaries for 3 days over a weekend. The mean age of participants was 67, with a range from ages 55 to 95 (Table 1). The sample comprised 45 women and 6 men. One female participant was Native American, while the remaining 50 participants were White.
PARTICIPANT DEMOGRAPHIC DATA N = 51
Thirty-eight participants were married, 12 were widowed, and 1 was divorced. Participants' years of formal education ranged from 0 to 19 years. The mean education level was 14 years. Forty-three study participants reported a high level of functional ability and rated their general health as good or excellent.
BLADDER DIARY DIURNAL VARIABLES REPORTED IN MEAN VALUES
Of the 51 participants, 42 reported they experienced episodes of urine leakage. Twenty-two participants reported leakage frequencies of daily to several times a day, 6 participants reported weekly leakage episodes, 10 reported monthly to yearly occurrences, and 4 reported variable leakage episode frequencies. Duration of the occurrence of leakage episodes ranged from months to 5 years n = 24) to more than 30 years (n = 3).
The bladder diary, as used in this study, was a collection of 8 ½-inch by 5-inch sheets of paper stapled together. The format for the diary was developed by Dr. Molly C. Dougherty, an expert nurse researcher, in her work with women, pelvic muscle changes, and urinary incontinence (M.C. Dougherty, personal communication, September, 1993). Each sheet contained columns in which participants recorded the time, type, and amount of fluid ingested, plus the occurrence and timing of voluntary voidings and involuntary urine leakage episodes (Figure 1). A column was also present for recording any activity a participant was involved in during the occurrence of a leakage episode. At the bottom of the bladder diary sheet, there was space for recording the time and amount of a "voided volume." One time a day participants were required to measure the amount of urine voluntarily eliminated from the bladder during one voiding. Data were recorded for a 3day period over a weekend.
Two pieces of equipment, a cup for measuring liquids, and a urine collection device were given to participants to assist them in completing thenbladder diaries. A plastic measuring cup was provided for participants, and they were instructed to use this cup to measure all oral fluid intake for the 3 days of data collection.
The cup had two measuring scales, one in ounces and one in milliliters (mL), and the total measurement capacity was 2 cups or 500 mL. Participants were told to use the scale with milliliters to record their intake amounts. This scale had 50 mL increments and participants were requested to estimate amounts in between these increments. The plastic cup had a long handle that turned downward, which allowed for easy grasping of the cup without touching the main portion holding the fluid. The cup was very sturdy and safe for use in the dishwasher and microwave oven.
The second piece of equipment given to participants was a disposable urine collection device. This device was placed in each participant's toilet and used to measure the voided volumes required each day of data collection. The container was made of a pliable plastic, and there was a measurement scale on the posterior portion of the container. The scale had ounces on one side and cubic centimeters on the other side. Participants were instructed to use either scale, depending on which mark was closest to the level of the urine in the container. The scale increments were 1 ounce for the side with ounces, or 50 cc for the side measuring cubic centimeters.
During meetings with participants in their homes, verbal instructions were provided regarding how to complete a bladder diary. Written instructions (Figure 2) were left with participants at the conclusion of the meetings. Participants also were asked about their general health and history of urinary continence. Diaries were maintained by participants for three 24-hour periods, including the weekend and one weekday. Participants selected either Friday, Saturday, and Sunday or Saturday, Sunday, and Monday for their 3 days of bladder diary data collection.
Prior to beginning the 3 days of data recording, it was suggested to participants that they measure all of their drinking containers at one time and record these measurements on the back of the bladder diary. This prevented participants from delaying their meals because of the necessity of measuring the liquids. For social events and other activities occurring outside the home setting, participants were allowed to estimate fluid intake amounts.
Participants were instructed to record all substances they ingested that would be liquid at room temperature. Because it would be impossible to measure some of these substances (e.g., ice cream, yogurt, gelatin) in the measuring cup, participants were asked to estimate the amounts consumed. Some participants stated they recorded the amount listed on the package, if the entire contents were consumed, as the intake amount on the bladder diary.
Voluntary diurnal and nocturnal voidings were recorded on the bladder diary simply by noting the time of occurrence and checking the appropriate column. Urine leakage episodes were recorded for time of occurrence and any activity the participant was involved in at the time of the leakage episodes. Each of the 3 days, participants were asked to record the amount of one voided volume of urine by using the collection device described previously. Most participants were instructed verbally on how to attach the urine collection device to the toilet. Occasionally, the investigator demonstrated this procedure to the participant.
Figure 1. The bladder diary form.
Figure 2. Written instructions for completion of the bladder diary.
Participants were provided with several telephone numbers to contact the investigator at any time during the bladder diary data collection period. Participants were encouraged to contact the investigator with any questions regarding the bladder diary. Also, the investigator notified participants they would be called once during the weekend of thenbladder diary data recording to discover how the process was going and learn if further clarification was needed. A follow-up meeting was scheduled with the participants to review the bladder diary data.
The follow-up meeting between the investigator and the participants, again at the participants' homes, was for the purpose of reviewing the data in the bladder diaries. Fluid intake amounts were calculated and compared to diurnal and nocturnal micturition frequencies. Bladder volumes also were considered in relation to fluid intake and voiding frequencies. The number of urine leakage episodes was reviewed, especially in relationship to activities by the participant at the time of the leakage. The investigator and participant reviewed the diary data together. Following this review, the investigator described options that could potentially assist the participants with their individual urinary-related concerns.
Options discussed included fluid and dietary modifications, such as restriction of caffeine in beverages and food, overall increase in fluid intake, decrease in fluid intake late in the evening, and use of fiber and fluid to prevent constipation. Simple behavioral changes also were discussed. These included the use of distraction techniques to assist participants in remaining dry until they arrived at the bathroom and suggesting participants spend enough time in the bathroom to adequately empty the bladder during each visit. More sophisticated options - including behavioral management techniques (e.g., bladder training, pelvic muscle exercises), medications, surgery, and other procedures for bladder control - then were discussed with participants, as indicated by either their desire for information or by the bladder diary data.
The mean oral fluid intake amounts for Days 1, 2, and 3 were 2,085 mL, 2,115 mL, and 1,911 mL, respectively (Table 2). Mean nighttime fluid intake amounts were minimal, ranging from 25 mL for Nights 1 and 3 to 34 mL for Night 2.
The number of daytime voidings for Day 1 ranged from 3 to 17 (mean = 8.2), for Day 2 ranged from 4 to 16 (mean = 7.8), and for Day 3 ranged from 4 to 15 (mean = 8). The average number of nighttime voidings for all three nights was 1.5. These voiding frequencies were similar to those reported by Wyman et al. (1991). In that study, average diurnal voidings ranged from 8.5 to 9.3, and nocturnal voidings ranged from 1.1 to 1.9.
The number of incontinent episodes differed between the two studies. Diurnal leakage episodes in the current study numbered from 0 to 9 for Day 1 (mean = 1.7) and Day 2 (mean = 1.5), and 0 to 7 for Day 3 (mean = 1.2). Nocturnal leakage episodes ranged from 0 to 2 for all three nights. Participants in this study included both individuals with urine leakage problems and continent individuals. In the Wyman et al. study (1991), leakage episodes ranged from 2.8 to 3.1 per 24-hour period, and all participants in the study had documented urine leakage problems.
Bladder diaries were used successfully in this study with residents of retirement settings. Capabilities required for completion of the bladder diaries included physical mobility, cognitive abilities such as comprehension and retention, manual dexterity, the ability to write legibly, and the motivation to consistently complete the diaries over a 3-day period. Many of the participants were quite active and led busy lives. However, they still exhibited the motivation to follow through with the bladder diary activities to learn more about their individual situations and perhaps discover something that could prove helpful.
The necessity of writing information in the bladder diaries can be difficult for active individuals. The use of tape recorders to capture information away from the home setting could free individuals for their activities, yet allow accurate documentation of bladder diary events on the written form at a later time. During the night, use of voice-activated recording devices could allow for recording of nighttime urinary events without the need for participants to turn on bright lights to enable them to write on the diary form.
Providing an audiotape or videotape of instructions for completion of bladder diaries could be another approach to facilitate participant compliance and minimize misinterpretation of written instructions. The use of audiotapes and videotapes for provision of information (i.e. instructions) and for data collection could be beneficial for older participants with vision problems or individuals experiencing writing difficulties.
Community-based health care is expanding in the United States. Increased attention is being directed to those interventions home health care nurses and other professionals can use to assist older people to maintain or regain functional independence. With consultation and guidance from nurses, older adults may be able to manage urinary incontinence in their current living situations. This could negate the need for relocation of older adults to residential care homes or nursing homes solely on the basis of the presence of incontinence.
Bladder diaries were used in this study as assessment tools to describe participants' voiding patterns. Review of this baseline information provided participants with enhanced self-awareness of their fluid intake and elimination situations. Potential approaches then were discussed for regaining, maintaining, or improving urinary continence. Diaries also can be used to monitor individuals' progress and evaluate the effectiveness of specific continence interventions. Bladder diaries are helpful tools because they are noninvasive and self-administered by the individuals within their own environment during day-to-day activities.
The promotion and maintenance of health in older people is important to preserve as many "successful" years as possible for older adults themselves and to limit health care expenditures for the nation. Many older adults live independently, are capable of self-care, and are motivated to undertake activities that will help them improve or maintain their daily lives. Through the use of bladder diaries, in conjunction with consultation and guidance from nurses, older adults may better understand and modify factors affecting their urinary health.
- Autry, D., Lauzon, R, & Holliday, P. (1984). The voiding record, an aid in decreasing incontinence. Geriatric Nursing, 5(1), 2225.
- Brown, J.S., Seeley, D.G., Fong, J., Black, D.M., Ensrud, K.E., & Grady, D. (1996). Urinary incontinence in older women: Who is at risk? Obstetrics & Gynecology, 87(5, parti), 715-721.
- Clay, E.C. (1978). Incontinence of urine: Part 2. Nursing Mirror, 146(10), 36-38.
- Hughes, E., & Anderson, CL. (1992). The voiding record: A new approach to an old problem. Geriatric Nursing, 13(2), 90-93.
- Lentz, G.L., & Stanton, S.L. (1992). Urinary diary: Designing a shorter diary [Abstract]. International Urogynecology Journal, 3(3), 69.
- Miller, J. (1990). Assessing urinary incontinence. Journal of Gerontological Nursing, 16(3), 15-19.
- Nygaard, I.E., & Lemke, J.H. (1996). Urinary incontinence in rural older women: Prevalence, incidence and remission. Journal of the American Geriatrics Society, 44(9), 1049-1054.
- Ouslander, J.G., Urman, H.N., & Uman, G.C. (1986). Development and testing of an incontinence monitoring record. Journal of the American Geriatrics Society, 34(2), 83-90.
- Rabin, J.M., McNett, J., & Badlani, G.H. (1993). Computerized voiding diary. Neurourology and Urodynamics, 12(6), 541-553.
- Rabin, J.M., McNett, J., & Badlani, G.H. (1996). "Compu-Void II": The computerized voiding diary. Journal of Medical Systems, 20(1), 19-34.
- Robb, S.S. (1985). Urinary incontinence verification in elderly men. Nursing Research, 34(5), 278-282.
- Wyman, J.F., Choi, S.C., Harkins, S.W., Wilson, M.S., & Fanti, J.A. (1988). The urinary diary in evaluation of incontinent women: A test-retest analysis. Obstetrics & Gynecology, 71(6), 812-817.
- Wyman, J.F., Elswick, R.K., Wilson, M.S., & Fanti, J.A. (1991). Relationship of fluid intake to voluntary micturitions and urinary incontinence in women. Neurourology and Urodynamics, 10(5), 463-473.
PARTICIPANT DEMOGRAPHIC DATA N = 51
BLADDER DIARY DIURNAL VARIABLES REPORTED IN MEAN VALUES