Alzheimer's disease and related dementias affect millions of older adults. While family members care for an overwhelming majority of individuals with dementia in home settings, many others reside in long-term care facilities (LTCFs). In an attempt to improve the quality of Hfe of individuals with dementia through individualized care and attention to their behavioral and functional problems, dementia special care units (SCUs) emerged rapidly in the 1980s. Currently, approximately 1 5% of LTCFs in the United States have SCUs. The number of SCUs is likely to continue to increase for 2 or 3 decades because of growth in the population of older adults and the increased rate of dementia associated with advancing age. While marketed as supportive living environments preferable to traditional LTC units, few studies have reported health or functional outcomes of individuals residing in dementia SCUs (Fitzwater, 1995; Phillips et al., 1997).
Urinary incontinence (UI), or involuntary urine loss, is a health condition that occurs frequently in individuals with dementia. Incontinence is estimated to affect 50% of the 1.5 million LTC residents in the United States (Fanti et al., 1996), with the majority of these residents experiencing multiple episodes of UI each day (Yu et al., 1990). The characteristics of UI in individuals with dementia have been described in community-dwelling (Ouslander, Zarit, Orr, & Muira, 1990) and LTC populations (Ouslander, Palmer, Rovner, & German, 1993; Ouslander, Uman, Urman, & Rubenstein, 1987; Palmer, 1990; Palmer, German & Ouslander, 1991; Yu et al., 1 990). However, little has been reported regarding UI in SCUs (Phillips et al, 1997).
The purpose of this study is to describe the prevalence, patterns, and complications of UI in older adults residing on dementia SCUs. Relationships between and functional status measures are discussed. The interventions currently used by SCU nursing staff to treat UI are specified and implications for clinical practice are offered.
While the problems of UI and dementia are often experienced concurrently by LTCF residents, cognitive impairment alone has not been shown to cause UI (Skelly & Flint, 1995). Genitourinary (GU) dysfunction, including urge incontinence, stress incontinence, and urinary obstruction causing overflow incontinence, has been diagnosed in urodynamic studies of older adults, including those with dementia (Griffiths, 1998; Pannili, Williams & Davis, 1988; Resnick, Valla, & Laurino, 1989; Yu et al., 1990). Impaired physical mobility, especially an inability to ambulate independently to the toilet, frequently contributes to UI in older adult residents of LTCFs (Jirovec, 1991b; Jirovec & Wells, 1990; Ouslander et al., 1993; Palmer, 1990; Yu et al., 1990).
In a study of the effect of SCU residence on the rates of functional status decline in individuals with dementia, SCU residents were more impaired in their decision-making capacity, but required less assistance with activities of daily living when compared to residents of traditional units (Phillips et al., 1997). Higher percentages of SCU residents experienced a decline in continence-related variables, including toileting skills and urinary and bowel continence. However, the researchers noted no statistically significant difference between SCU residents and those living on traditional LTCF units for nine outcome measures, leading them to conclude SCU residence alone does little to delay functional decline in individuals with dementia.
This study used a descriptive correlational survey design to specify the problem of UI in residents of SCUs. The institutional review board of a large midwestern university approved the procedure for participant recruitment and data collection. After the signed consent form was received from the resident's legal representative, a nurse research assistant completed the health record review. Data were collected from January to November 1997. Data obtained during the health record review were analyzed with descriptive and correlational statistics using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL) 9.0 for Windows (Microsoft, Redmond, WA) software.
The Incontinence Patterns Tool (IPT), developed by the principal investigator (J.K.P.S.) for this study, was used to collect data (Specht, 1995). The IPT focused on the following continence characteristics:
* Urinary and fecal continence status when admitted to LTCF and SCU.
* Date UI first noted in the health record.
* Frequency, amount, and time of day of UI episodes.
* Staff assessment of UI.
* Interventions used to treat UI.
* Complications of UI.
Clinical data collected included length of time since diagnosis of dementia, nursing and medical diagnoses, fluid intake, and medications. Demographic data included age, gender, and length of stay. Data were gathered from all sections of a resident's health record including the Minimum Data Set (MDS), Resident Assessment Protocols (RAP), nursing care plan, nursing notes, assistant personnel daily logs, and physician entries (Morris, Murphy, & Nonemaker, 2000).
The two most recently completed MDS forms were used to collect data on the following variables: bladder continence; mobility; activity; mental status; physical status; and UI complications including falls, pressure ulcers, skin excoriation, and urinary tract infection (UTI). Either the initial, quarterly, or annual MDS may have been reviewed to encompass the 6-months prior to the data collection. A pilot test of the IPT demonstrated availability of the desired continence data in the health record. Data were transcribed onto the IPT from the health record by nurse research assistants trained in the use of the instrument by the principal investigator and who had clinical and research experience in dementia SCUs.
Setting and Participants
The settings for this study were dementia SCUs located in 13 LTCFs in Iowa (n - 11) and Wisconsin (n = 2). The SCUs in this study were previously the setting of a large clinical trial of Family Involvement in Care (FIC) - a nursing intervention designed to build partnerships between family and professional caregivers of individuals with dementia (Maas &C Swanson, 1992). The proprietary status of the SCUs included for-profit (n = 4), not-for-profit (n = 7), and government (n = 2). The number of beds for the SCUs ranged from 10 to 60, with an average of 27 beds per facility. All SCU residents were eligible to participate in the continence study. No resident was excluded because of age, continence status, or cause of cognitive impairment.
A convenience sample of 145 SCU residents with dementia participated in the continence study. Ninety-three (64%) women and 52 (36%) men were enrolled. The mean age of the residents was 83.3 years. The majority of the residents (n = 110, 76%) were admitted directly to the dementia SCU where the median length of stay was 2.4 years (range 24 days to 7.7 years). The median length of stay within the LTCF was 2.75 years (range 24 days to >26 years). Table 1 compares selected resident characteristics by gender.
Figure 1. Time from long-term care admission to onset of urinary incontinence. No residents became incontinent during the Day 15 to Day 31 period.
Prevalence of Urinary Incontinence
At the time of LTCF admission, 48% (n = 70) of the SCU residents were incontinent of urine and 46% (n = 67) were urinary continent. The admission continence status of 6% (n = 8) of the residents was undetermined because of conflicting data in the health record. Men were more likely than women to be incontinent at the time of admission (?2 = 7.488, df=2,p = 0.02). At the time of data collection, the prevalence of UI had risen to 8 1 % (n = 1 1 8) with no significant gender difference in continence status (x2 = 2.684, df= 1, p = 0.1).
Of those incontinent on admission, eight individuals (5.5%) had experienced a remission and were currently urinary continent. The length of time between LTCF admission and onset of UI was available for 53 residents. Forty-two percent (n = 22) of these SCU residents were incontinent within the first 6 months following admission. The average time between admission and onset of UI was 298 days (range 1 to >16 years). Figure 1 displays the frequency categories for the onset of UI following LTCF admission.
Nursing and Medical Diagnoses
The most common nursing diagnoses and RAPs for the residents are displayed in Table 2. The number of nursing diagnoses ranged from O to 15 with a median of 7 (SD = 3.2) nursing diagnoses per resident. As expected in a dementia SCU, altered thought process or the cognitive loss and dementia RAP (n = 113, 78%) was the resident health condition most frequently identified by SCU nurses.
Of the 118 residents with UI, 55% (n = 65) had at least one continencerelated nursing diagnosis including altered urinary elimination or UI RAP (n = 50), toileting self -care deficit (n - 16), stress incontinence (n = 3), total incontinence (n = 2), urge incontinence (n = 2), or functional incontinence (n = 1). Two residents who were continent were diagnosed with toileting self-care deficit. The SCU residents with UI were more likely to have a nursing diagnosis of altered urinary elimination, bathing self-care deficit, or impaired physical mobility.
The most common medical diagnosis categories for the SCU residents are shown in Table 3. The number of medical diagnoses ranged from 1 to 20, with a median of 8 (SD = 4.8) medical diagnoses per resident. No significant differences existed in the medical diagnoses categories based on resident continence status. Fortythree percent (n = 63) of the residents had at least one GU-related medical diagnoses listed by the physician in the medical history. The most common conditions were history of GU surgery (« = 36), UTI (n = 22), benign prostatic hypertrophy (n = 10), cystocele (n = 5), GU cancer (n = 5), neurogenie bladder (n = 2), atrophie vaginitis (n = 2), urinary retention (n = 2), and congenital GU abnormalities (n = 2). Only 2.1% (n = 3) of the residents had a current medical diagnosis of bladder incontinence.
NURSING DIAGNOSES IN SPECIAL CARE UNITS
Urinary Incontinence Patterns
Understanding the patterns of Ul experienced by persons with involuntary urine loss is necessary for establishing individualized treatment programs. For this study, the patterns examined included awareness of toileting needs, level of urinary control, and amount and frequency of urine loss. Although cogniuvely impaired, many residents were conscious of their toileting needs. Fifty-five percent (n = 79) of the residents were aware of the need to void. Forty-eight percent (n = 69) requested toileting assistance from nursing staff and were cognizant of wetness following an incontinence episode. Individuais who were continent of urine were more likely to be aware of the need to void (χp 2 = 27.718, df = 2, p = 0.000), to ask for toileting assistance (χp 2 = 31.580, df = 2, p = 0.000), and to be aware of wetness (χp 2 = 31.675, df= 2,p = 0.000) than residents who were incontinent.
The residents' level of urinary control was ranked on the following scale from MDS bladder continence ratings: (1) full control (continent); (2) usually controlled or indwelling catheter (UI episodes weekly, but not daily); (3) minimal control (Ul episodes daily, but some control present); or (4) absent (always incontinent). Full control over involuntary urine loss was noted for 96% (n = 26) of the continent residents and for 3% (n = 4) of the residents with UI.* Of the residents with Ul, 36% (n = 42) usually controlled urine loss, 25% (n = 29) had minimal urinary control, and 36% (n = 43) were reported to have no control over involuntary urine loss.
The amount of urine lost with UI episodes was classified as large, small, or constant dribbling. Large amounts of urine loss were documented for 27% (n = 39) of the residents. An additional 21% (n = 31) of the residents typically experienced small amounts of urine loss. Constant dribbling was the usual UI pattern for 10% (n = 15) of the residents. Men were more likely to have large UI episodes (χp 2 = 7.502, df = l, p = 0.006), and women were more likely to have small UI episodes (χp 2 = 6.675, df= 1, p = 0.01).* There were no significant gender differences for those with constant dribbling (χp 2 =1.830, df = 1, p = 0.17).
Frequency of UI episodes is displayed in Figure 2. Fifty-nine percent (n = 70) of SCU residents with UI had multiple daily episodes of urine loss. Of the residents with daily urine loss, 33% (n = 23) had UI episodes every 2 to 3 hours or more frequently, and 66% (n = 47) had predictable patterns of incontinence occurring once or twice every 8 hours. More women (n = 26) than men (n = 5) experienced involuntary urine loss on a weekly basis.
The assessment and documentation by nursing staff of SCU residents* incontinence patterns were often incomplete. The onset of UI, whether beginning at home or in the facility, was not recorded for 63% (n = 92) of the residents. Therefore, neither the duration of UI or periods of remission from involuntary urine loss could be determined for most residents. The frequency of UI episodes was not noted in 14% (n = 20) of the resident's records while 27% (n ~ 39) of the resident's records failed to note the amount of urine lost with an incontinent episode.
Fluid Intake Patterns
The amount of daily fluid intake, an important indicator of overall hydration status and useful for the scheduling of nocturnal toileting and fluid distribution (Griffiths, McCracken, Harrison, Oc Gormley, 1993), was not documented for 68% (n = 98) of the residents. In addition, information was lacking about the residents' fluid seeking (n = 92, 63%) and fluid accepting (n = 82, 57%) behavior. Fluid intake was calculated for 47 residents. The median fluid intake was 1,200 cc and ranged from 600 cc to 2,400 cc per day. Of the residents (n = 53) for whom fluid seeking, or the ability to locate fluids when thirsty, was documented, most (n = 43) did not engage in this behavior independently. Of the 63 residents whose fluid-accepting status was documented, nearly half (« = 31) would accept fluids from their caregivers whenever offered.
Functional status was divided into four broad categories: mobility, activity, mental status, and physical health. Functional status data were obtained from the most recently completed MDS. Mobility was defined as having control over bodiîy movements. Activity level was defined as the ability to walk. Mental status was defined as the resident's responses to the environment. Physical health described the residents' current overall health status. Table 4 provides a comparison of the residents* functional status based on their continence status.
MEDICAL DIAGNOSES CATEGORIES IN SPECIAL CARE UNITS
The majority of the residents surveyed were in fair (n = 88, 61%) to good (n = 25, 17%) physical health. As expected of a dementia SCU, 72% of the residents were confused (n = 104). Few residents (n = 12) were unable to respond to their caregivers. The majority of these residents were incontinent (n = II),
Figure 2. Frequency of urinary incontinence episodes.
Classification of mental status as alert or apathetic was more common in individuals with UI. Mobility and activity were important indicators of continence status. AU immobile residents (n = 17) were incontinent of urine. Ninety percent (n = 38) of the residents who were chairbound (n = 36) or bedfast (n = 6) were incontinent of urine (χp 2 = 3.229, df = 1, p = 0.07). Ninety-seven percent (n = 29) of the residents whose mobility was very limited (n = 13) or immobile (n = 17) were incontinent of urine (χp 2 = 5.834, df= 1,p = 0.01). Fortyseven percent (n = 68) of the residents were independently ambulatory and an additional 24% (n = 35) could walk with minimal assistance. Nonetheless, 78% (w = 80) of these active SCU residents were incontinent.
FUNCTIONAl. STATUS BY CONTINENCE STATUS
Urinaiy Incontinence Interventions
Incontinence aids and scheduled toileting were the two interventions most frequently employed by SCU nursing staff to manage involuntary urine loss. Incontinence aids, defined as any device designed to collect urine, were used by 72% (n = 105) of the residents. Incontinence briefs and padding (n = 93) were used more frequently than catheters (n = 5). Fifteen incontinent residents (10%) did not wear any type of UI aid. These residents most often experienced UI episodes on a weekly (n = 9), rather than a daily (n = 5), basis. Four continent residents (3%) wore UI collection devices at least occasionally.
Scheduled toileting, often defined in the nursing care plan as "check and change every 2 hours," was the basis of incontinence care for 69% (n = 100) of the residents. Prompted voiding, the promotion of urinary continence through the use of timed verbal toileting reminders and positive social feedback for successful toileting (Palmer, 1996), was prescribed by nurses from seven facilities for a small number of residents (n = 17, 12%). No residents were treated with either pelvic muscle exercises or bladder training to improve their control of UI episodes.
Forty-four percent (n = 64) of the residents were prescribed medications that may effect urinary continence. These medications included the diuretic furosernide (n = 31, 21%), diuretics other than furosemide (« = 15, 10%), calcium channel blockers (n = 12, 8%), and tricyclic antidepressant agents (n = 7, 5%). Of the residents prescribed a diuretic (n = 43), 77% (n = 33) were incontinent of urine. Pharmacological agents for improving urinary continence status were prescribed to very few residents. Oxybutynin (DJtropan), a urinary tract antispasmodic used in treatment of detrusor overactivity or urge incontinence, was prescribed to one male resident. An androgen hormone inhibitor, finasteride (Prosear), was prescribed to two male residents. Estrogen therapy for the treatment of stress incontinence or atrophie vaginitis in postmenopausal women was prescribed to three female residents.
Pharmacological treatment of UI complications included the use of barrier creams for impaired skin integrity and anti-infective agents for UTIs. Barrier creams to protect perinea! skin from excessive contact with UI moisture were prescribed for 11% (n = 16) of the residents. Barrier creams were applied most frequently (n = S) to residents with UI episodes occurring at least once every 4 to 8 hours and those with large amounts of urine loss (n = 6). Anti-infective medications were used to treat 33 of 53 (62%) laboratory-diagnosed UTIs.
Urinary Incontinence Complications and Associated Conditions
The complications and associated conditions of incontinence examined in this study included pressure ulcers, skin excoriation, fecal incontinence, UTIs1 falls, and urine odor. The MDS data were used for the first five variables, while the presence of urine odor was most often found in the nursing notes. Table 5 reports the number of SCU residents with UI complications. Residents with UI had more documented instances of UI complications than those who were urinary continent
The occurrence of pressure ulcers and skin excoriation was sparsely documented in the MDS. Twenty residents, three of whom were urinary continent, had problems with urine odor documented during a 6-month time period. Falls and UTIs occurred more frequently in individuals with UI. Fecal incontinence was the condition that most often accompanied UI in SCU residents, with 17% (n = 25) having fecal incontinence at the time of LTC admission, and 54% (n - 78) having the problem at data collection. No urinary continent individual had fecal incontinence.
The most important implication of the study is that dementia SCU residents are likely to respond to behavioral interventions for UI with increased urinary continence. The majority of SCU residents in the study had slight to full control of their body movements (79%), could walk unaided or with assistance (71 %), and had at least minimal control over urine loss (70%). In addition, many residents were aware of the need to urinate (55%), had fewer than six incontinent episodes per day (54%), could ask to use the toilet (48%), and were aware of wetness after UI (48%). These resident characteristics have been found to be predictors of successful treatment of UI with behavioral interventions (Ouslanderetal., 1 995; Schnelle, 1990).
In the SCUs examined, few residents with UI or at risk for developing involuntary urine loss were prescribed behavioral interventions such as habit training, prompted voiding, or individualized scheduled toileting. Rather, UI was managed through application of incontinence aids, "check and change" programs, and every 2-hour scheduled toileting. In light of research showing that individuals with dementia can be successfully treated for UI (Jirovec, 199Ia; Jirovec, 1991b; Ouslander et al., 1995; Schnelle, 1990), the narrow range of nursing interventions used to treat UI in SCU residents is of concern. While some interventions, such as pelvic muscle exercises or bladder training, may be unsuitable for most residents who were cognitively impaired, reliance solely on a continence care system of check and change and incontinence aids is also inappropriate.
FREQUENCY OF CONDITIONS ASSOCIATED WITH URINARY INCONTINENCE (MINIMUM DATA SET)
Palmer (1990) noted that as cognitively impaired nursing home residents' mobility improved, so did their continence status. Nursing interventions that maintain or extend a resident's mobility may also improve continence status (Jirovec, 199Ia; Schnelle et al., 1995). Prompted voiding is a behavioral technique recommended by the Agency for Health Care Policy and Research (AHCPR) Urinary Incontinence Clinical Practice Guidelines for the treatment of UI in caregiverdependent adults (Fanti et al-, 1996).
In addition to providing scheduled toileting reminders and assistance, prompted voiding encourages nursing staff to frequently ambulate residents, thus helping to maintain this very important activity of daily living skill. Prompted voiding has been shown to decrease the number of daily incontinent episodes in LTCF residents who have impaired cognition and mobility (Colling, Ouslander, Hadley, Eisch, & Campbell, 1992; Creason et al-, 1989; Jirovec, 199Ia; Jirovec, 1991b; Schnelle et al., 1989). Persons with urinary elimination patterns similar to SCU residents in the current study, are likely to maintain high levels of urinary continence when assisted by caregivers using the prompted voiding technique (Ouslander et al., 1995; Schnelle, 1990). Unfortunately, only 12% (n = 17) of the residents were prescribed the prompted voiding intervention by SCU nurses.
Another important finding of this study is that urinary continence assessment and documentation in dementia SCUs is often incomplete. Assessment of the cause, type, and pattern of UI is essential prior to the implementation of any incontinence intervention. A nursing care plan for treatment of UI was in place for only 55% of the residents with UI. Furthermore, nursing documentation of resident continence patterns was inconsistent as evidenced by the lack of information about the type of incontinence, amount of UI voiding, frequency and timing of UI episodes, fluid intake, and the residents' awareness regarding urine loss.
The current study's findings echo the results of a retrospective chart audit of a 223-bed teaching nursing home that examined nurses' documentation of patient continence care needs (Petrucci, McCormick, & Scheve, 1987). The researchers noted that continence status was inconsistently recorded between the six documentation tools examined.
Only 2.5% of the nursing care plans identified UI. Nursing personnel were more likely to document continence information on forms that used continence status cue words. Following the establishment of a continence research unit, the researchers reviewed continence care documentation. In the follow-up study, it was found that forms completed by professional nurses had significantly higher documentation rates than forms completed by nursing assistants, and 36% of the nursing care plans identified UI (Palmer, McCormick, & Langford, 1989).
The current study's findings should be viewed cautiously for the following reasons. First, the data were obtained from a retrospective health record review. Resident continence status characteristics known to SCU staff but undocumented in the health record were unavailable to the researchers. Second, not every person residing in one of the participating dementia SCUs is represented in the sample. The continence-related characteristics of the residents who did not enroll could differ from those who participated. Third, the SCUs in this study have a history of participating in nursing research studies. The nursing assessment, documentation, and continence interventions on these units may differ from SCUs that choose not to be involved in nursing research.
Finally, in the current study there were discrepancies in the documentation of urinary continence status between the health record and the MDS. This is consistent with the differing opinions related to the use of the MDS for studying UI in LTCFs. Crooks, Schnelle, Ouslander, and McNees (1995) reported a moderate correlation (r = 0.49, p < 0.001) of the MDS continence ratings to researcherconducted wet check ratings, but also found wide variability within MDS categories and between facilities for these two methods of rating UI severity. However, other researchers have found the MDS to be useful for determining potentially reversible causes of UI in LTCF residents (Brandéis, Baumann, Hossain, Morris, & Resnick, 1997). Future studies should consider direct assessment of continence status in SCU residents.
The current level of assessment, documentation, and intervention for UI in SCUs is deplorable. In fact, there is minimal intervention for UI. Many SCU residents have the potential to maintain or regain urinary continence. This potential cannot be realized without improved assessment, documentation, and treatment of UI.
With limited nursing resources available in LTCF, it is essential to make all interventions as effective as possible. With targeted continence assessment, nurses can set treatment priorities based on a resident's potential for regaining continence. Continence assessment based on the MDS and RAP is not sufficient to determine the type and pattern of UI to guide selection of appropriate intervention, necessitating the use of additional assessment tools. Likewise, systematic documentation of resident continence status is essential for evaluating the effectiveness of the selected intervention and deciding how to modify the intervention if it is not effective. The Urinary Continence, Urinary Elimination, and Self-Care: Toileting Outcomes of the Nursing Outcomes Classification (NOC) (Iowa Outcomes Project, 1997) is an easy and effective way to evaluate and document changes in residents' continence status.
Nursing interventions to improve urinary continence are essential for the enhancement of the quality of life of SCU residents. Urinary incontinence limits residents* interaction with others and participation in activities. Because these aspects of life quality also are limited by dementia, it is important that further constraints by incontinence not be imposed. Further, interventions that do not maintain or improve continence status do not help residents and are a poor use of nurse and staff resources. The results of this study indicate there is great potential for successful treatment of UI on special care units that could address the high personal costs of incontinence, lead to improved quality of life for residents, and enable more effective use of staff resources.
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NURSING DIAGNOSES IN SPECIAL CARE UNITS
MEDICAL DIAGNOSES CATEGORIES IN SPECIAL CARE UNITS
FUNCTIONAl. STATUS BY CONTINENCE STATUS
FREQUENCY OF CONDITIONS ASSOCIATED WITH URINARY INCONTINENCE (MINIMUM DATA SET)