Urinary Incontinence in Critically Ill Older Adults


Introduction
Over 317,000 older adults fracture their hips annually (“HCUP facts and figures,” 2005) and are hospitalized for medical management and surgical repair. Older adults represent 38% of discharged patients from nonfederal hospitals and have greater risks from hospitalization than younger patients (R. M. Palmer, 2006).
Many of these individuals enter the acute care setting continent of urine but leave incontinent wearing an indwelling catheter, an absorbent product, or both. In a study of hospitalized female hip-fracture patients, 21% of women who were continent prior to their hospitalization for hip-fracture repair became incontinent during hospitalization. The risk factors associated with becoming incontinent in these women were admission from a nursing home, presence of confusion, use of wheelchair or walking device, and prefracture dependence on others for ambulation (M. H. Palmer, Baumgarten, Langenberg, & Carson, 2002).
Urinary incontinence is considered a potentially life-threatening condition (Wilson, 2006). It is associated with frailty (Miles et al., 2001); falls (Brown et al., 2000); depression (van der Vaart, Roovers, de Leeuw, & Heintz, 2007); diabetes mellitus (Smith, 2006); coexisting complaints of fatigue, cough, and fecal incontinence (Stenzelius, Mattiasson, Hallberg, & Westergren, 2004); and long-term care placement (A. Morrison &Levy, 2006). In community-dwelling women urinary incontinence is associated with physical decline measured by walking speed and sit-to-stand speed. Cognitive decline, however, was associated with difficulty in coping with incontinence (Huang, Brown, Thom, Fink, & Yaffe, 2007).
In stroke patients urinary incontinence had a significant impact on long-term functional outcomes. Although the proportion of patients with urinary incontinence decreased over time, incontinent stroke survivors were four times more likely to be institutionalized after their first post stroke year than continent survivors (Kolominsky Rabas, Hilz, Neundoerfer, & Heuschmann, 2003).
Evidence exists that urinary incontinence can be prevented and effectively treated in older adults, including the frail elderly (Fonda et al., 2005). Little evidence from the acute care setting is available, especially in critically ill older adults, but overwhelming evidence from the community and long-term care settings indicate that the key to effective treatment is prompt and comprehensive assessment (CMS Manual System 2005; Fonda et al.). The need for best practices related to urinary elimination in critically ill older adults is especially compelling. Extended use of urinary catheters, that is, beyond 48 hours, in elderly surgical patients in the acute care setting is associated with poor patient outcomes, including urinary tract infections and postoperative mortality (Wald, Epstein, Radcliff, & Kramer, 2008). In an effort to reduce these complications, Medicare will no longer reimburse hospitals for hospital-acquired catheterassociated urinary tract infections after October 1, 2008 (Wald & Kramer, 2007). Nurses caring for critically ill older adults will need to use measures to preserve urinary continence throughout the illness and to provide incontinence treatment that maintains the maximal feasible continence level relative to patient condition and medical management.
The purpose of this chapter is to provide background information about urinary incontinence and to discuss evidence-based approaches meeting the urinary continence needs of critically ill older adults.
Physiology of Micturition
Micturition, a complex physiologic process that involves the storage and emptying of urine from the bladder, is not completely understood. Neural control of micturition involves the cortex, posterior hypothalamus, midbrain, and pons (Griffiths & Tadic, 2008). In the absence of dysfunction during the storage phase (sympathetic system activation) during which the bladder fills, afferent signals are sent to the sacral cord, to the periaqueductal gray (PAG), located in the midbrain, and to the prefrontal cortex. Through the prefrontal cortex, inhibitory signals are sent back to the PAG, which inhibits the excitation of the pontine micturition center (PMC). As a consequence, the bladder walls remain relaxed, continuing to stretch, and the urinary sphincters remain contracted. At this point, micturition is at an unconscious level. As the bladder continues to fill and the wall to stretch, the intensity of the afferent signals to the spinal cord grows. When the intensity exceeds a threshold, at about 300 to 400 cc of urine in the bladder, the frontal lobe is activated and conscious inhibition of micturition occurs (Vogel, 2001). The individual is aware of the increasing need to void, but continues to inhibit the voiding urge until toilet facilities are located and accessed.
When emptying occurs under conscious control, the prefrontal inhibition of the PAG is removed, thus allowing the PAG to excite the pontine micturition center (Griffiths & Tadic). Consequently, efferent signals are sent to the sacral reflex center, located between S2 and S4. With this parasympathic system activation, the detrusor contracts because of cholinergic/muscarinic stimulation. In coordination with bladder contraction, the bladder outlet and urethra, under alpha-adrenergic stimulation, are relaxed to allow urine to empty. The nucleus of Onuf, located in the sacral ventral horns, innervates the external urinary sphincter via the somatic nerve, causing sphincter relaxation.
Table.1
Age-Related Changes That Can Contribute to Urinary

Age Related
Change: Potential Effects on Continence
1.   Bladder ultrastructure on electron microscopy
a.    Disjunction pattern
b.   Muscle and axon degeneration
·        Bladder overactivity and urge incontinence
·        Impaired bladder contractility, increased residual
·        urine, and decreased functional bladder capacity
2.   Bladder function
a.    Decreased capacity
b.   Increased involuntary detrusor contractions
c.    Decreased contractility during voiding
d.   Increased residual urine
Increased likelihood of urinary symptoms and incontinence
3.   Urethra.
Decreased closure pressure in women
Increased likelihood of stress and urge incontinence
4.   Prostate.
Increased incidence of benign prostatic obstruction
Increased likelihood of urinary symptoms and incontinence
5. Decreased estrogen (women)
·        Increased incidence of atrophic vaginitis and related symptoms
·        Increased incidence of recurrent urinary tract infections
·        Decreased urethral pressure
6. Increased nighttime urine production
Increased likelihood of nocturia and nighttime incontinence
7. Altered central and peripheral neurotransmitter concentrations and actions
Increased likelihood of lower urinary tract dysfunction
8. Altered immune function
Increased likelihood of recurrent urinary tract infections
. From “Incontinence in the Frail Elderly,” by D. Fonda, C. E. DuBeau, D. Harari, J. G. Ouslander, M. H. Palmer, & B. Roe, 2005. In Incontinence, Management Vol. 2. P. Abrams, L. Cardozo, S. Khoury & A. Wein (Eds.), p. 1170. Paris: Health Publication Ltd. Copyright 2005 by the International Continence Society
continence in Frail Elderly People
Age-Related Changes That Affect Urinary Continence
Although age does not cause urinary incontinence, some age-related anatomical and physiologic changes to the lower urinary tract can increase vulnerability. These changes include reduced bladder capacity and voided volumes and an increase in the number of uninhibited detrusor contractions (Fonda et al., 2005). In men, benign prostatic hypertrophy increases the incidence of bladder neck obstruction. Decreased circulating estrogen levels in women lead to increased incidence of atrophic vaginitis and decreased urethral pressure (Fonda et al.) (see Table.1).
Bladder Function and Aging
Recent research on aging effects on the female lower urinary tract reveals a decline in detrusor contractility, bladder sensation, and urethral sphincter function. Bladder capacity does not appear to diminish significantly (Pfisterer, Griffiths, Schaefer, & Resnick, 2006). There is little aging effect on 24-hour urine production (mean 1,765 mL) and micturition frequency (8 voids per 24 hours is considered the norm). In addition, urethral profile length did not change but the maximum urethral closure pressure declines with age (Pfisterer, Johnson, Jenetzky, Hauer, & Oster, 2007).
Men also experience aging effects on their lower urinary tracts. In a cross-sectional study with men aged 40 to greater than 80 years old, older men experienced an increase in postvoid residual urine volumes, decreased peak flow rate, and voided volume. Although prostate volume increased with age, no significant differences existed in these parameters between obstructed and nonobstructed men (Madersbacher et al., 1998). Impaired contractility seen in older adults, instead of aging, may be caused by myogenic, ischemic, or neurogenic factors and is evidenced by decreased urinary flow rates and elevated postvoid residual urine volumes (about 50 mL or less) (DuBeau, 2006).
Urinary continence is a socially constructed term. It assumes voluntary control of urine and that urination occurs at socially acceptable times and in socially acceptable places. The lack of continence carries a social stigma (“NIH State-of-the-Science Conference,” 2007). Many older adults can still relate stories of embarrassment over their own childhood enuresis, and describe feelings of powerlessness over being incontinent in their old age (Hagglund & Ahlstrom, 2007).
Continence should also be viewed as a dignity issue. The United Nations declared dignity as a human right in 1948 (“The universal declaration of human rights: 1948– 2008,” 2007). On behalf of incontinent nursing home residents, a human rights complaint was filed by the Ontario Federation of Labour to the Human Rights Commission (Walkom, 2008). The case was subsequently dismissed, but it started a new ongoing dialogue about the link between continence and dignity.
In addition, recent changes in the Centers for Medicare and Medicaid Services (CMS) Guidelines related to hospital-acquired catheter-related urinary tract infections emphasize the need to assess at admission the presence of conditions that place the older adult at risk and the need to prevent catheter-related urinary tract infections during a hospital stay (Hess &Rook, 2007). Thus, nurses play a central role in providing proactive assessment and interventions to prevent, treat, and manage urinary incontinence.
Urinary Incontinence: Definition of Terms
The International Continence Society provides a succinct definition of urinary incontinence: “any complaint of any involuntary leakage of urine” (Abrams et al., 2002, p. 168). Urinary incontinence, a symptom that occurs in the storage phase of micturition, although prevalent in older adults, is not caused by age (“NIH State-of-the-Science Conference,” 2007). At the most functional level, incontinence occurs when intravesical pressure exceeds intraurethral pressure. Nurses can assess and identify the type of incontinence their patients are experiencing and use evidence-based interventions to treat or manage incontinence.
Two major types of urinary incontinence are stress urinary incontinence and urge urinary incontinence. A combination of symptoms of both stress and urge urinary incontinence is called mixed incontinence (Abrams et al., 2002). In community-dwelling studies of older adults, women have higher prevalence of urinary incontinence than do men (Goode et al., 2008).
Stress Urinary Incontinence
Stress urinary incontinence is caused by physical (not emotional) stress, resulting from physical activity or positioning. During the storage phase of normal micturition, the pressure in the bladder (intravesical pressure) remains lower than the pressure within the urethra (intraurethral pressure). When an individual vomits, coughs, sneezes, or laughs intraabdominal pressure rises. This action results in a corresponding increase in intravesical pressure and normally intraurethral pressure will also increase. For individuals with stress urinary incontinence, intraurethal pressure either does not increase or does not increase sufficiently to maintain the pressure gradient. Under conditions when intravesical pressure is greater than the intraurethral pressure, urine escapes from the bladder.
One reason for the failure of the urethral pressure to increase can be that the periurethral muscles surrounding are weak from acquired or congenital factors, see Table.2. Stress urinary incontinence occurs more often in women than men (except for men who have had prostate cancer surgery or damage to their pelvic floors from surgery, injury, or disease).
Urge Urinary Incontinence
Urge urinary incontinence involves bladder function abnormalities, rather than the sphincter function abnormalities found with stress urinary incontinence. Urge urinary incontinence is also a symptom of overactive bladder. Normally the bladder fills passively, and involuntary (uninhibited) bladder contractions are absent or suppressed. However, when there are contractions of a sufficient magnitude that are not inhibited during the filling cycle, involuntary urine loss may occur. Uninhibited bladder contractions may also result from deconditioned voiding reflexes (Wein, 1986). For example, some older adults resort to frequent voiding and maintaining chronic low bladder volume in an attempt to avoid incontinent episodes. This can lead to reduced bladder capacity and, with time, thickening of the bladder wall, aggravating the decreased tone and increasing involuntary bladder contractions.
A cerebral etiology of urge incontinence has been proposed. It is theorized that global impairment of cerebral perfusion and regional underperfusion of the frontal lobes results in urge incontinence and reduced bladder sensation (Griffiths et al., 1994). In detrusor overactivity, the smooth muscle may exhibit abnormal mechanical activity and a reduced response to intrinsic nerve stimulation (Brading, 1997). Brading proposed that changes in the properties of the detrusor allow transmission of local neural activity throughout the bladder wall, resulting in a coordinated detrusor contraction (Brading).
Individuals with urge urinary incontinence often report having a sudden and overwhelming urge to urinate and they may lose urine while attempting to reach the toilet. The prevalence of urge urinary incontinence was higher in community-dwelling older women than older men in one large survey. In women aged 65 to 74 years, 19.1% reported urge incontinence as compared to 8.2% of men in the same age group (Stewart et al., 2003). Urge urinary incontinence was also a significant factor in institutionalization for men (Nuotio, Tammela, Luukkaala, & Jylha, 2003).

Table.2
Definition of Terms for Lower Urinary Tract Symptons (LUTS)


Lower Urinary Tract Symptoms (LUTS)
Definition
Increased day time frequency
The complaint by the patient who considers that he/she voids too often by day.
Nocturia
The complaint that the individual has to wake at night one or more times to void.
Urgency
The complaint of a sudden compelling desire to pass urine, which is difficult to defer.
Urinary incontinence
The complaint of any involuntary leakage of urine.
Stress urinary incontinence
The complaint of involuntary leakage on effort or exertion, or on sneezing or
coughing.
Urge urinary incontinence
The complaint of involuntary leakage accompanied by or immediately preceded
by urgency.
Mixed urinary incontinence
The complaint of involuntary leakage associated with urgency and also with
exertion, effort, sneezing, or coughing.
From The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-committee of the International Continence Society. Journal of Neurourology and Urodynamics, 2002, Vol. 21, pp. 167–178. Copyright 2002 by the International Continence Society


Mixed Urinary Incontinence
The International Continence Society definition of mixed incontinence is, “the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing” (Abrams et al., 2002, p. 168). Mixed urinary symptoms such as problems with storing urine (urinary incontinence and frequency, urgency) and voiding symptoms (incomplete bladder emptying) are prevalent in adults over 75 years of age (Stenzelius et al., 2004).
Urinary Incontinence Related to Toilet-Access Issues
People with normal bladders and urinary function can still experience functional incontinence. This type of incontinence occurs when an individual has a full bladder but has no access to a toilet. Hospitalized and nursing home residents unable to use the toilet independently may experience functional incontinence if they do not get assistance to the toilet in time.
Overactive Bladder
Overactive bladder (OAB) is defined as “urgency with or without urge urinary incontinence, usually with frequency and nocturia” (Wein & Rovner, 2002, p. 7). Occurrence of OAB symptoms is unpredictable (Balkrishnan, Bhosle, Camacho, & Anderson, 2006). OAB is reported to have a significant effect on quality of life (Milsom et al., 2001) by decreasing self-esteem and increasing the fear of being incontinent in public (Wein & Rackley, 2006). OAB is characterized by involuntary bladder contractions during the storage of urine, which may be spontaneous or provoked, for example, by a local irritant (i.e., bladder stone or toxin) (J. Morrison et al., 2002).
Impaired contractility in the presence of detrusor hyperactivity (DHIC) was identified by Resnick and Yalla as a cause of urinary incontinence in older adults (Resnick & Yalla, 1987). Recent research on detrusor overactivity reveals a wide range of symptomats including decreased bladder capacity and increased bladder sensation (Pfisterer, Griffiths, Rosenberg, Schaefer, & Resnick, 2006). The relationship between detrusor overactivity and urge urinary incontinence is not clear, and a method to classify severity of detrusor overactivity has been attempted (Miller, DuBeau, Bergmann, Griffiths, & Resnick, 2002).
Urgency
Urgency is defined as “the complaint of a sudden compelling desire to pass urine, which is difficult to defer” (Abrams et al., 2002). In a 10-year study with an older population, urgency and urge urinary incontinence significantly predicted death in men, after adjusting for socioeconomic status, smoking, and alcohol use (Nuotio et al., 2002).
Frequency
Frequency is defined as more than eight voids in a 24-hour period (Milsom et al., 2001). In a multicountry study with 16,776 subjects older than 40 years, frequency was the most prevalent symptom (reported by 85% of the sample) (Milsom). Both frequency and urgency increased with age and there was little difference in prevalence in men and women.
Nocturia
Nocturia, waking from sleep to void one or more times a night, is a prevalent condition that increases with age with 90% of people over the age of 80 years reporting it (Fonda et al., 2005). In a secondary analysis of a longitudinal study Johnson and his colleagues found that hypertension, older age, and diuretic use were associated with two or more episodes of nocturia in community-dwelling older adults (Johnson, Sattin, Parmelee, Fultz, & Ouslander, 2005). In a population-based study older men reported nocturia more frequently than women (Tikkinen, Tammela, Huhtala, & Auvinen, 2006).
Individuals with overactive bladder symptoms are at risk of experiencing incontinent episodes because of their increased need for toilet access. Another urinary symptom that can occur in critically ill older adults is bladder outlet obstruction, which can lead to urinary retention.
Bladder Outlet Obstruction
According to the International Continence Society, bladder outlet obstruction (BOO) is a lower urinary tract symptom. Obstruction of the bladder outlet may result in obstructive symptoms such as decreased urine flow; hesitancy; sensation of incomplete emptying; and irritative symptoms such as urgency, frequency, nocturia, and dysuria (Dmochowski, 2005). Urinary retention is also a sign of BOO. Griffiths refers to “bladder failure,” a condition that exists in older adults whose bladders do not contract adequately to empty the bladder of urine (Griffiths, 2003).
Urinary Retention
Urinary retention is characterized as being either acute or chronic; pain is present with acute retention, when a person is unable to void. Chronic urinary retention is generally defined as a postvoid residual urine volume greater than 300 mL (Kaplan, Wein, Staskin, Roehrborn, &Steers, 2008). The underlying etiology for urinary retention is not clear but has been postulated as being caused by one or more of the following: (a) mechanical obstruction leading to increased resistance to flow, (b) detrusor sensory or motor innervation disruption, and (c) overdistension of the detrusor (Thomas, Chow, & Kirby, 2004).
The leading cause of acute urinary retention in men is increased prostate gland volume, most commonly caused by benign prostatic hypertrophy (BPH) in which the bladder neck is obstructed and flow is impeded (Kolman, Girman, Jacobsen, & Lieber, 1999). Risk factors for acute urinary retention in men also include increased age and decreased peak urinary flow rates (< 12 ml/sec) (Jacobsen et al., 1997) and medication usage such as those with anticholinergic effects (Meigs et al., 1999). Recent developments in the understanding of detrusor functioning indicate that detrusor underactivity may occur in the absence of bladder outlet obstruction in men (Thomas, Cannon, Bartlett, Ellis-Jones, &Abrams, 2004). Detrusor underactivity is defined as “contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/ or a failure to achieve complete bladder emptying in a normal time span” (Abrams et al., 2002, p. 175). Performing a transurethral resection to relieve bladder outlet obstruction did not alleviate voiding symptoms for men with detrusor underactivity.
Urinary retention is considered rare in women, although norms for postvoid residual urine volumes for women are not well established. In one study investigating the relationship between postvoid residual volumes and urinary tract infections with 204 postmenopausal women, the mean postvoid residual volume was 53.13 ml. In women with higher postvoid residual urine volumes a higher rate of urinary tract infections was reported (Stern, Hsieh, & Schaeffer, 2004). Evidence also exists that estrogens have a role in detrusor function, and in this study there was a statistically significant relationship between oral estrogen therapy and postvoid residual urine volumes (women on estrogen replacement therapy had lower postvoid residual urine volumes than women not on estrogen replacement therapy). The use of oral estrogen replacement therapy, however, appeared to have no protective effect against recurring urinary tract infections (Stern et al.).
Risk factors for urinary retention have been identified in different clinical populations. For example, urinary retention is prevalent in patients who have had an ischemic stroke. Other correlates included cognitive impairment, diabetes mellitus, aphasia, poor functional status, and urinary tract infections (Kong & Young, 2000). Fecal impaction is often cited in the clinical literature as contributing to urinary retention, yet little evidence has been provided to support this claim. For example, fecal impaction was not a statistically significant factor in either urinary retention or detrusor underactivity in nursing home residents who underwent urodynamic testing (Starer, Likourezos, & Dumapit, 2000). But another study showed that the greatest risks for urinary retention in women were fecal impaction, advanced age, history of diabetes mellitus, and use of medications with anticholinergic effects (Borrie et al., 2001).
Inability to transfer independently, that is, dependence on others to transfer, was found to be directly correlated with fecal impaction and urinary retention, thus leading the authors to conclude a third factor, immobility, may play a key role in both urinary and bowel emptying (Starer et al., 2000). Transfer ability also plays a role in the development of urinary incontinence during the first year of nursing home admission (M. H. Palmer, German, & Ouslander, 1991). It was also found to be an independent predictor of hip fracture (Walter, Lui, Eng, & Covinsky, 2003).
Postoperative urinary retention was noted in 39.5% of patients who underwent orthopedic surgical procedures. Associated factors included increased age and the amount of intravenous fluids infused in the 24-hour postoperative period (Wynd, Wallace, & Smith, 1996). The large amount of fluids infused during the perioperative interval was implicated in high catheterization rates in elderly male veterans undergoing surgery with spinal or general anesthesia (Kemp &Tabaka, 1990). Factors associated with urinary retention in older women admitted to a geriatric rehabilitation center (63% had orthopedic surgery) included cognitive impairment, presence of chronic conditions, impaired mobility, and polypharmacy (Hershkovitz, Manevitz, Beloosesky, Gillon, & Brill, 2003). Concern over instrumentation of the urinary tract and its relation to sepsis has led to calls for identification of patients who may be at risk for developing urinary retention (Wroblewski & del Sel, 1980) and for nonpayment for catheterassociated urinary tract infections (Wald & Kramer, 2007).
Management of urinary retention and the development of urinary tract infections in surgical patients have been the subjects of numerous studies. Straight catheterization in the recovery room, to prevent bladder overdistension, was found to have no benefit in preventing overdistension. The authors, however, found an increase in urinary tract infections in patients who had received straight catheterization (Hozack, Carpiniello, & Booth, 1988). Michelson and colleagues noted that use of indwelling catheters on a short-term basis reduced the incidence of urinary retention in hip and knee replacement patients (Michelson, Lotke, & Steinberg, 1988). Their findings support an earlier study that found indwelling catheters superior to straight catheterization and they did not increase the risk of urinary tract infections (Oishi et al., 1995). Catheterization is often used to preemptively prevent bladder distension or as a response to a patient’s inability to empty the bladder after surgery (Knight &Pellegrini, 1996; Kumar, Mannan, Chowdhury, Kong, & Pati, 2006). The strongest correlate for bacterial colonization is duration of catheter use (Cornia, Amory, Fraser, Saint, & Lipsky, 2003). Indwelling catheters are often used in the immediate postoperative period to avoid bladder overdistension, but they can act as a single-point restraint. To prevent urinary tract infections and colonization, the duration of indwelling catheterization is usually limited to 24 to 48 hours (Wald, Epstein, & Kramer, 2005).
Urinary retention is a prevalent problem, especially after orthopedic surgery, but its etiology is not clear and controversy exists over the amount of postvoid residual urine volume that is clinically significant (amounts vary from 50 to 250 ml) (Yarnold, 1999). Thus assessing postvoid residual urine volumes during critical illnesses, especially in individuals with potential for urethral obstruction or incomplete bladder emptying, is a prudent nursing measure. Portable bladder ultrasounds may be used for this purpose to avoid unwarranted catheterization (Newman, 2008).
Incident Urinary Incontinence
Hospitalized patients, like Mrs. Meyers in the case study, may normally be dry but become incontinent during hospitalization. Other terms used to describe incontinence that occurs in usually continent individuals are transient incontinence and acute-onset incontinence. These terms are used to imply the potentially reversible nature of incontinence. The underlying assumption is that once the underlying factor or condition is treated, the incontinence will resolve. In critically ill older adults it is difficult to determine if new incontinence is the start of an established pattern of incontinence or transient or acute-onset incontinence. The important point is not to assume incontinence is inevitable or caused by age. An incontinence history and an assessment for the underlying causes of incontinence must be done. Major risk factors for urinary incontinence include both reversible and irreversible factors, including cognitive, functional, infectious, metabolic, and pharmacologic factors.
Cognitive Factors
Delirium is considered a medical emergency and requires immediate attention (Fernandez, Callahan, Likourezos, & Leipzig, 2008) (see chapter 26 on delirium). Older adults can become confused from medication reactions, infections, or other medical conditions. While they are confused, they may forget how and where to go to the bathroom or even be unaware that they need to empty their bladder.
Urinary incontinence is highly prevalent in patient populations exhibiting cognitive impairment resulting from dementia (Fonda et al., 2005). The proposed mechanisms include cerebral neuropathy, specifically in the frontal lobes (Griffiths et al., 1994), and the inability to carry out activities of daily living independently (Fonda).
Confusion during hospitalization increases the risk of urinary incontinence (M. H. Palmer, Myers, &Fedenko, 1997). Proposed reasons for this finding include inability to toilet independently because of confusion and lack of assistance to toilet in a timely manner. In bivariate analyses men developed urinary incontinence at twice the rate of women recovering from hip-fracture surgery, yet in the presence of dementia no significant differences between men and women in urinary incontinence incidence was detected (M. H. Palmer et al.).
Functional Factors
Urinary continence is dependent on accessing appropriate toilet facilities in a timely manner. Evidence exists that people with limited mobility and the inability to transfer independently experience higher prevalence and incidence of urinary incontinence than people with unimpaired mobility (Fonda et al., 2005). Incontinent older adults receiving assistance with ambulation often experience improvement in incontinence (Schnelle et al., 2003), indicating that urinary incontinence may often be caused by lack of access or inadequate access to toilet facilities rather than specific pathophysiology. DuBeau noted that impaired mobility posed greater risk for urinary incontinence than cognitive impairment in nursing home residents (DuBeau, 2005). Preexisting dependent ambulation also increases risk of hospital-acquired urinary incontinence in female hip-fracture patients (M. H. Palmer et al., 2002).
Another consequence of immobility is constipation and, if left untreated, fecal impaction. Hard stool blocking the rectum becomes almost impossible to pass without medications or enemas. Impaction is considered a cause of incontinence (Schnelle & Leung, 2004) although the mechanism is unclear. Thus, critically ill older adults on bedrest or unable to access toilet facilities independently are at risk of developing functional decline, fecal impaction, and perhaps, urinary incontinence.
The care plan should reflect information that patients with functional limitations are at risk of becoming incontinent and toilet alternatives and behavioral interventions may be appropriate to use.
Infectious Factors
Urinary tract infections may irritate the bladder and cause both strong urges to urinate and a sensation of needing to urinate frequently. If a urinary tract infection is suspected, especially in a catheterized patient, it must be treated immediately because of the risk of life-threatening urosepsis. Urinary tract infections are the most frequent cause of bacteremia and they are associated with high mortality (Tal et al., 2005). Because many research reports on urinary tract infections in the elderly do not provide a consistent definition of a urinary tract infection, the prevalence and incidence of urinary tract infection are difficult to determine. In some reports, the presence of 100,000 colonies of a uropathogen per milliliter of urine is considered an indication of a urinary tract infection. Bacteriuria, however, is not considered a urinary tract infection unless symptoms of infection are present (CMS Manual System, 2005). Research indicates little correlation between bacteriuria and symptoms of a urinary tract infection in elderly patients (Hedstrom, Grondal, & Ahl, 1999). In a preoperative screening, Johnstone and colleagues found that 14.8% of women had a positive culture (10
colonies/ milliliter), although it is not reported how many were symptomatic. In another study with hip-fracture patients, 38% had a positive urinary culture on admission to the hospital. The most common bacteria was Escherichia coli (45%) (Johansson, Athlin, Frykholm, Bolinder, & Larsson, 2002).
Symptoms of urinary tract infections in noncatheterized older adults include at least three symptoms: (a) increase in temperature of greater than 2 degrees Fahrenheit or single temperature measurement that is greater than 100 degrees Fahrenheit; (b) new or increased burning pain on urination, frequency, or urgency; (c) new flank or suprapubic pain or tenderness; (d) change in the character of the urine (e.g., new bloody urine, foul smell, or amount of sediment) or new pyuria or microscopic hematuria as reported from a laboratory; and (e) worsening cognitive or functional status (e.g., confusion, decreased appetite, unexplained falls, recent-onset incontinence, lethargy or decreased activity). In catheterized patients at least two symptoms are needed to indicate a urinary tract infection (CMS Manual System, 2005).
Some urinary tract infections are considered to be a complication of urinary tract instrumentation, specifically catheterization. Catheter-associated urinary tract infections entail additional costs for diagnostic tests and extra medications; median costs for a catheter-associated urinary tract infection was $356 (1998 dollars) (Tambyah, Knasinski, & Maki, 2002). Catheter-related bacteriuria has been associated with increased mortality (Saint & Chenoweth, 2003), but controversy exists over prophylactic antibiotic use to prevent urinary tract infections (Cardosi, Cardosi, Grendys, Fiorica, & Hoffman, 2003). In general, antibiotic use for asymptomatic bacteriuria is not recommended (CMS Manual System 2005; Midthun, Paur, Bruce, & Midthun, 2005). The use of silver-coated catheters has been advocated to reduce the prevalence of urinary tract infections (Hashmi, Kelly, Rogers, & Gates, 2003; Kassler & Barnett, 2008; Maki & Tambyah, 2001) although others did not find a reduction in urinary tract infections associated with silver-hydrogel catheter use (Lai & Fontecchio, 2002). A Cochrane Systematic Review on symptomatic urinary tract infections in elderly women found studies to be of poor quality and optimal treatment duration could not be determined (Lutters & Vogt, 2002).
After a woman’s ovaries stop producing estradiol, estradiol levels decrease in the urogenital tract. As a result urogential tissue atrophies, becoming thin, dry, and susceptible to inflammation. Atrophic vaginitis is inflammation of vaginal tissues and symptoms can include urinary urgency, polyuria, and incontinence (Castelo-Branco, Cancelo, Villero, Nohales, & Julia, 2005). Guidelines for treatment of atrophic vaginitis include topical estrogen and use of water-soluble lubricants, vaginal moisturizers, oral or topical administration of vitamin E, and some Chinese herbs (Castelo-Branco et al.). The role atrophic vaginitis plays in the development of urinary incontinence is not clear but its treatment may relieve urinary symptoms.
Metabolic Factors
Diabetes mellitus is a known risk factor for urinary incontinence in women and the risk increases as the duration of diabetes increases (Lifford, Curhan, Hu, Barbieri, & Grodstein, 2005). The continence mechanism and detrusor contractibility are impaired because of neuropathy, thus incomplete bladder emptying may occur. In a crosssectional study with 1,017 postmenopausal women, those with diabetes had more severe urinary incontinence, were less able to completely empty their bladders, and had more discomfort with urination than did women without diabetes (Jackson, Scholes, Boyko, Abraham, & Fihn, 2005). In the presence of heart disease the risk for urinary incontinence for a diabetic is even greater.
An older adult with an abnormally high blood glucose level, which happens with uncontrolled diabetes mellitus, may urinate in frequent large amounts that overwhelm the bladder and thus result in urinary incontinent episodes.
Pharmacologic Factors
Many medications affect the urinary tract, including diuretics, anticholinergics, beta blockers, alpha adrenergic agonists, and alpha adrenergic antagonists, (see Table.3) Polypharmacy and medications that are potentially inappropriate for older adults (see Try This for Beers, available at http://consultgerirn.org/uploads/File/trythis/ issue16_2.pdf). Criteria for potentially inappropriate medications for the elderly (Molony, 2008) should be monitored closely for their impact on urinary function. Older adults may be using multiple medications that share similar pharmacological activity on the bladder that may increase the risk of urinary incontinence (Ruby et al., 2005).

Table.3
Risk and Associated Factors for Urinary Retention

Risk Factor
Reference
Cognitive impairment
(Kong & Young, 2000)
Diabetes mellitus
(Kong & Young)
Poor functional status
(Kong & Young)
Urinary tract infections
(Kong & Young)
Fecal impaction
(Starer et al., 2000)
Advanced age
(Starer et al.)
Medications with anticholinergic effects
(Borrie et al., 2001)
Immobility
(Starer et al.)
Amount of intravenous fluids administered perioperatively
(Wynd, Wallace, & Smith, 1996)
Polypharmacy
(Hershkovitz et al., 2003)
Presence of chronic conditions
(Hershkovitz et al.)
Decreased peak urine flow in men
(Abrams et al., 2002)
Ischemic stroke
(Kong & Young)



Assessment
In the long-term care and community settings, assessment includes a comprehensive history and physical examination. Essential components of the history include history of urinary incontinence and past or current treatment of urinary incontinence. Factors that have an impact on neurological status of anatomical structures include: history of pelvic or abdominal surgery, radiation, trauma, back surgery, or trauma. This assessment may not be feasible to conduct with a critically ill older adult, but documentation in the medical record may provide information relevant to urinary function.
Comorbidities, especially those that result in frailty (Miles et al., 2001), difficulty ambulating or transferring (M. H. Palmer et al., 1991), and stroke (Goode et al., 2008) may play a role in the development or worsening of urinary incontinence. As noted earlier, the medication history, especially medications with urologic activity, is essential to creating a care plan to lessen or reverse urinary incontinence.
Useful information from a bladder record is similar to many elements in standard intake and output charts. These include: (a) times and amount of voiding; (b) whether voiding was continent or not; (c) timing of bowel movements; (d) fluid intake, including intravenous fluids and amount of caffeinated beverages ingested. Not only is evidence of the physiologic functioning of the gastrointestinal and urinary tracts obtained, but information about elimination patterns and toileting habits is also provided (Sampselle, 2003). Although a 3- or 7-day bladder record has been recommended in healthy community-based older adults (Locher, Goode, Roth, Worrell, & Burgio, 2001; Tincello, Williams, Joshi, Assassa, & Abrams, 2007), this may not be possible during hospitalizations with a short length of stay. The very act, however, of keeping a bladder record serves as a prompt or cue for caregivers to provide toileting and to create selfawareness in the older adult of the need to void (Sampselle).
Information about patient preference for incontinence treatment is limited. In one study with cognitively intact inpatients, many functionally dependent individuals preferred catheters over medications and scheduled toileting. The authors suggested that these individuals either did not want to be dependent on caregivers for toileting assistance or they had little faith in the ability of the staff to achieve timely toileting (Pfisterer et al., 2007).
Physical Examination
Postvoid residual volumes should be assessed to rule out urinary retention resulting from incomplete bladder emptying that can occur from peripheral neuropathy secondary to diabetes mellitus (Newman, 2008) or changes in normal voiding stances (i.e., men trying to void while in bed rather than standing next to the bed). Skin should be assessed for incontinence-associated dermatitis (Gray, 2007). Incontinence-associated dermatitis-affected skin exhibits inflammation in skin folds or other areas exposed to urine or feces. The skin may appear bright red and have maculopapular red rash with satellite lesions, indicating cutaneous candidiasis. In addition, the patient may report that the skins itches and burns (Gray). Skin exposed to urine and feces requires special care and protectants to prevent or reduce breakdown. In critically ill older adults with diarrhea or fecal incontinence, a rectal trumpet has been used to manage the collection of fecal material and maintain perineal skin integrity (Grogan & Kramer, 2002). A 32-French nasopharyngeal airway was used as a rectal trumpet and findings revealed that this appliance was effective is containing fecal matter and helping to restore skin integrity. In addition, pressure ulcer prevention measures should be instituted.
For the critically ill older adult able to ambulate or sit up in a chair, an environmental assessment should also be conducted. Capezuti and colleagues (2008) recommend seating height to be approximately 120% of the individual’s lower leg length to promote sit-to-stand movements and to prevent falls. For individuals dependent on others for toileting needs, access to call bells or other devices to communicate with caregivers is especially critical.
Gender-specific physical examination includes prostate examination in men to determine presence of prostatic enlargement that may contribute to incomplete emptying, especially when they are unable to assume their normal voiding stance. In women, if their condition permits, urogenital tissue should be examined for atrophic vaginitis, purulent discharge, and evidence of prolapse. This information assists in deciding the course of treatment. For example, behavioral interventions would be ineffective in treating incontinence that is caused by inflammation or obstruction. When prolapse is present, longitudinal evidence suggests that vaginal descent is not associated with stress or urge incontinence (Bradley, Zimmerman, Wang, & Nygaard, 2008).
Information from the assessment must be reviewed and interdisciplinary efforts (e.g., nursing, medicine, pharmacy, physical therapy, etc.) to treat factors that cause incident incontinence (i.e., fecal impaction) and affect urinary tract function (i.e., diabetes mellitus) must occur concurrently with interventions to manage incontinence (i.e., behavioral interventions or urinary collection devices).
Treatment
Behavioral therapies are the first treatment of choice for incontinence in institutional and community-dwelling adults because of low adverse effects and evidence of their effectiveness. Measurement of the effectiveness of these interventions includes patient satisfaction, and dryness level, that is the number of dry voids divided by the number of total voids multiplied by 100. Bladder records have also been used in the evaluation of treatment (Bryan & Chapple, 2004) but no evidence of their use in the acute care or critical care environment is available.
Despite the lack of evidence in health care settings where critically ill older adults are treated, these preventive measures should still be attempted. As concern over hospital-acquired complications and patient safety increases, the need for nursing measures designed to preserve function, such as urinary continence, and to prevent complications (e.g., falls associated with incontinence, urinary tract infections associated with indwelling catheter use) is compelling.
For example, in the place of a bladder record used in long-term-care settings, critical care nurses can use information already documented on intake and output forms to determine voiding patterns. Further information about factors that affect continence may be revealed when medication sheets that display the type, timing, and amount of administered medications are reviewed for medications that affect the urine storage and emptying functions of the lower urinary tract.
The paucity of evidence for treatment effectiveness is also compounded by the lack of evidence-based outcomes, including quality-of-life measures, for critically ill older adults. Figure.1 displays an algorithm to use to guide treatment. Medical justification for inserting and keeping an indwelling catheter in place, that is, the need for a strict intake and output record, may preclude the use of behavioral interventions. However, the need to measure urine volumes may be met with the use of portable bladder ultrasound rather than an indwelling catheter (Newman, 2008).
Prompted Voiding
Prompted voiding involves caregiver prompting to elicit requests from the older adult for: (a) toileting assistance; (b) efforts to self-toilet; (c) provision of toileting assistance; and (d) social reinforcement from the caregiver for toileting-assistance requests, being continent between toileting episodes, and voiding into the toilet when assistance was provided (M. H. Palmer, 2005). Indicators of success for the intervention include: bladder capacity greater than 200 mL and less than 700 mL, ability to recognize the need to void, maximum voided volume of greater than 150 mL, postvoid residual urine volume less than 100 mL, and ability to void when given assistance to the toilet (Lyons & Specht, 2000). Because prompted voiding requires staff adherence to the protocol, staff performance models have been developed. One model involved statistical quality control (Schnelle, Cruise, Rahman, & Ouslander, 1998) and the other involved supervisory nurses who observed direct care workers performance of the prompted-voiding intervention (Burgio et al., 1990). Bladder capacity and postvoid residuals are easily measured with bladder ultrasound and if the person is physically able to cooperate with toileting, a trial of prompted voiding should be tried to prevent or treat urinary incontinence. It may take up to 3 days to determine if the older adult responds to prompted voiding by having fewer incontinent episodes, more continent voidings, and increased number of requests for assistance with toileting.

Figure.1
Critically ill older adults flow chart.

Critically ill older adults flow chart



Timed Voiding
Timed voiding involves a fixed schedule of offering assistance to toilet. Timed voiding is the most commonly used intervention for continence in health care settings (Ostaszkiewicz, Johnston, & Roe, 2004). Not enough evidence exists, for or against, to recommend timed voiding as an effective toileting schedule (Ostaszkiewicz et al.). As with prompted voiding, timed voiding may be effective if the individual cooperates with toileting assistance and there is evidence that the number of incontinent episodes decreases when timed voiding is used.
Habit Training
Habit training or habit retraining is used when rehabilitating the bladder is unfeasible. Before starting a habit-training program, the individual’s voiding pattern is discerned from keeping a 3-day bladder record. The goal is to preempt an incontinent episode by adjusting a toileting schedule according to the individual’s voiding pattern. Because the older adult is a passive participant in this intervention, it requires strict adherence by the caregiver for habit training to be effective. A systematic literature review found limited evidence to determine if continence improvement is worthwhile in relation to its labor-intensive nature (Ostaszkiewicz, Chestney, & Roe, 2004). Habit training may be effective with older adults who have a discernable voiding pattern but cannot delay voiding. Nursing staff members consistently assigned to the individual may observe the voiding pattern and be able to preempt an incontinent episode by offering toileting assistance.
Toilet Substitutes
Toilet substitutes to prevent incontinence include urinals and bedside commodes. The goal is to provide increased toilet access to individuals with limited mobility or energy levels. Several models of female and male urinals are available (Fader, 2003). Although there is little research on the use of urinals and bedside commodes with critically ill older adults, these toilet substitutes may provide the necessary toilet access as healing occurs and as the older adult regains strength to ambulate or transfer to a commode.
Catheterization
Bladder decompression to prevent or treat urinary retention are major reasons for indwelling catheter use but Jain and colleagues found that indwelling catheters were inappropriately used for the management of urinary incontinence in 21% of the hospitalized medical patients studied (Jain, Parada, Davis, & Smith, 1995). Failing to discontinue an indwelling catheter that does not have a medical justification is considered an indicator of poor care (Landi et al., 2004). Criteria used to justify long-term catheterization include wound contamination from urinary incontinence or fecal incontinence, urinary retention that cannot be managed medically or surgically, terminal illness, and failure of other treatments accompanied by a patient preference for catheterization (The Merck Manual of Geriatrics, 2008). Recommendations exist to use indwelling catheters only for justified medical reasons and for the shortest period of time (Leone et al., 2003).
Physicians are sometimes not aware that their patients have an indwelling catheter. In one study, for example, physicians were unaware of 28% of catheterizations in their patients (Saint et al., 2000). Saint and colleagues (Saint, Lipsky, & Goold, 2002) suggested that indwelling catheters act as a single point restraint. Researchers reporting on a national survey found that 23% of older surgical patients had an indwelling urinary catheter (Wald et al., 2008). Patients discharged to extended-stay facilities with an indwelling catheter had greater odds for rehospitalization for urinary tract infections and for death after adjusting for age and comorbid conditions (Wald et al., 2005). Nonpayment for hospital-acquired catheter-associated urinary tact infections provides hospitals a financial incentive to find other means to manage urinary elimination. In another national survey, 12% and 9% of non-Veterans Administration (VA) hospitals used condom catheters and suprapubic catheterization, respectively. The researchers conducting this study noted that the use of these alternatives can lower bacteriuria rates. Use of systems to monitor which patients have indwelling catheters and to measure the duration of catheterization may also help prevent hospital-acquired urinary tract infections (Saint et al., 2008).
If an indwelling catheter is indicated because of the patient’s medical condition or need for close monitoring of intake and output, a silver-coated catheter may reduce catheter-associated urinary tract infections (Kassler & Barnett, 2008). The guideline published by the Centers for Disease Control and Prevention in 1981 to prevent catheter-associated urinary tract infections recommends insertion of the catheter using aseptic technique and a closed drainage system (Centers for Disease Control and Prevention, 1981). In addition, automated reminders to either remove or continue using an indwelling catheter may reduce catheterization duration (Saint et al., 2008).
Absorbent Products
Urine containment strategies, such as absorbent underpads for beds and wearable products (such as pads and pull-up briefs) should only be used after assessment for the type of incontinence, amount of urine lost, and self-care abilities of the individual. Absorbent products, however, are often employed in the absence of assessment (Connor & Kooker, 1996) because health care providers often lack necessary knowledge about incontinence and its assessment and treatment (Cooper & Watt, 2003) and do not view urinary incontinence as an important clinical condition (Molander, Sundh, & Steen, 2002). In the nursing home setting, 99% of incontinent patients used absorbent products (Watson, Brink, Zimmer, & Mayer, 2003), yet little is known about the shortand long-term effects of the use of absorbent products on patient outcomes and on subsequent follow-up by health care providers to assess and treat urinary incontinence.
Medications
Several medications administered orally that have anticholinergic effects are available for urge urinary incontinence. The overall goal of anticholinergic medication use for urge incontinence is to reduce the intensity of detrusor contraction (Roxburgh, Cook, & Dublin, 2007). These medications may be contraindicated for frail older adults, those with multiple chronic conditions, or those taking multiple medications. Evidence exists that the dual use of bladder anticholinergic medications (e.g., oxybutynin or tolterodine) with cholinesterase inhibitors for dementia may actually result in faster rate of functional decline in high-functioning nursing home residents than in those taking cholinesterase inhibitors without use of anticholinergic medications for incontinence (Sink et al., 2008). No medications are currently available in the United States to treat stress urinary incontinence. Medications causing urinary incontinence are listed in Table.4; medications used to treat urinary incontinence are listed in Table.5.
Table.4
Medications That Can Cause or Contribute to Incontinence in Frail Older Adults and Medication’s Effects on Continence

Medications
Effects on Continence
Alpha adrenergic agonists


Increase smooth muscle tone in urethra and prostatic capsule and may precipitate obstruction, urinary retention, and related symptoms
Alpha adrenergic antagonists

Decrease smooth muscle tone in the urethra and may precipitate stress incontinence in women
Angiotensin converting enzyme (ACE) inhibitors
Cause cough that can exacerbate incontinence
Antimuscarinic agents
May cause urinary retention and constipation that can contribute to incontinence
Calcium channel blockers
May cause urinary retention and constipation that can contribute to incontinence
Cholinesterase inhibitors
Increase bladder contractility and may precipitate incontinence
Diuretics
Cause polyuria and precipitate incontinence
Opioid analgesics

May cause urinary retention, constipation, confusion, and immobility–all of
which can contribute to incontinence
Psychotropic drugs
·        Sedatives
·        Hypnotics
·        Antipsychotics
May cause confusion and impaired mobility and precipitate incontinence
Some agents have anticholinergic effects
Other drugs
·        Calcium channel blockers (pyridines)
·        Gabapentin
·        Glitazones
·        Nonsteroidal anti-inflammatory agents
Can cause edema, which can lead to polyuria while supine and exacerbate nocturia and nighttime incontinence

Table 5.  
Medications to Treat Urinary Incontinence

Medication
Mechanisms
Dose
Comments
Bladder Outlet Obstruction in Men with Urge or Overflow Incontinence
Alfuzosin
Adrenergic blockage
10 mg by mouth once/day
Relieve symptoms of male outlet obstruction, may reduce postvoid residual volume and outlet resistance, and may increase urinary flow rate.
Effect occurs within days to weeks. Adverse effects include hypotension, fatigue, asthenia, and dizziness.
Doxazosin

1–8 mg by mouth once/ day

Prazosin


0.5–2 mg by mouth b.i.d.

Tamsulosin


0.4–0.8 mg by mouth once/day

Terazosin


1–10 mg by mouth once/Day

Dutasteride

5 alpha-Reductase inhibition
0.5 mg by mouth once/day
These medications reduce prostate size and obstructive symptoms and make transurethral resection of prostate glands greater than 50 grams, less likely to be needed.
Finasteride

5 mg by mouth once/day
Adverse effects are minimal and consist of sexual dysfunction (example: decreased libido, erectile dysfunction)
Detrusor Overactivity in Urge Incontinence
Darifenacin

Anticholinergic muscarinic antagonism effects, selective M3

Extended-release: 7.5 mg by mouth once/day

Adverse effects are similar to
those of oxybutynin but because of bladder selectivity may be less severe.
Solifenacin

Anticholinergic effects, selective M1 and M3 muscarinic antagonism

Extended-release: 5–10 mg by mouth once/day

Adverse effects are similar to those of oxybutynin, but because of bladder selectivity may be less severe.
Imipramine
Tricyclic antidepressant, anticholinergic, and alpha-agonist effects
25 mg by mouth at night; may increase in increments of 25 mg to a maximum dose of 150 mg
Is useful for the treatment of nocturia
Oxybutynin

Smooth muscle relaxation, anticholinergic, nonselective muscarinic, and local anesthetic effects Immediate release:2.5–5 mg by mouth .i.d. to q.i.d. Extended release:5–30 mg by mouth once/day Transdermal: 3.9 mg twice/week

Efficacy may increase over time. Adverse effects include anticholinergic effects (example: dry mouth, constipation) that may interfere with adherence and worsen incontinence. Adverse effects are less severe with extended-release and transdermal forms.

Tolterodine

Anticholinergic effects, selective M3 muscarinic antagonism

Immediate release: 1–2mg by mouth b.i.d.
Extended release: 2–4 mg by mouth once/day
Efficacy and adverse effects are
similar to those of oxybutynin, but long-term experience is limited. Because M
receptors are targeted, adverse effects are less severe than those of oxybutynin. Dose reduction is needed in patients with severe renal impairment
Trospium
Anticholinergic effects
Immediate release: 20 mg by mouth b.i.d. (20 mg once/day in renal insufficiency)
Adverse effects are similar to those of oxybutynin.
Dose reduction is needed in patients with renal impairment.
Summary
Despite limited information about evidence-based interventions specifically designed for critically ill older adults, nurses can act to promote urinary continence and protect patient dignity. One common barrier to widespread implementation to these interventions has been resistance to changing behaviors that have traditionally promoted staff convenience, most notably the use of urine containment strategies such as absorbent products or the use of indwelling catheters without medical justification. The standard of care of critically ill older adults should include a comprehensive assessment for urinary elimination needs and the patient’s self-care abilities prior to the development of a care plan and initiation of behavioral and other interventions designed to treat or manage urinary incontinence.
Evidence that urinary continence assessment and care planning has occurred could include the documentation of: (a) duration of indwelling catheterization; (b) use of urinary containment measures such as condom catheters, female and male urinals, and absorbent products; (c) incidence and type of hospital-acquired urinary tract infections; (d) incidence and type of hospital-acquired skin complications related to incontinence; (e) self-reported patient and family satisfaction with care; and (f) patients’ report of preservation of their sense of dignity.
Typical outcome measures for incontinence interventions have traditionally included wetness levels and quality of life. In critically ill older adults, outcome measures need to be developed to determine if the feasible maximal level of continence is being achieved.
Resources for Patient Education
·        National Institute on Aging, Age Page: Urinary Incontinence. To order this Age Page in English or Spanish, visit www.niapublications.org
·        American Geriatrics Society Foundation for Health in Aging, Patient Handout: Urinary Incontinence and Its Treatment. www.healthinaging.org
·        National Association for Continence www.nafc.com
·        Simon Foundation www.simonfoundation.org
References
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Balkrishnan, R., Bhosle, M. J., Camacho, F. T., & Anderson, R. T. (2006). Predictors of medication adherence and associated health care costs in an older population with overactive bladder syndrome: A longitudinal cohort study. Journal of Urology, 175(3 Pt 1), 1067–1071; discussion 1071–1072
Borrie, M. J., Campbell, K., Arcese, Z. A., Bray, J., Hart, P., Labate, T., et al. (2001). Urinary retention in patients in a geriatric rehabilitation unit: Prevalence, risk factors, and validity of bladder scan evaluation. Rehabilitation Nursing, 26(5), 187–191.
Brading, A. F. (1997). A myogenic basis for the overactive bladder. Urology, 50(6A Suppl.), 57–67; discussion 68–73.
Bradley, C. S., Zimmerman, M. B., Wang, Q., & Nygaard, I. E. (2008). Vaginal descent and pelvic floor symptoms in postmenopausal women: A longitudinal study. Obstetrics & Gynecology, 111(5), 1148–1153.
Brown, J. S., Vittinghoff, E., Wyman, J. F., Stone, K. L., Nevitt, M. C., Ensrud, K. E., et al. (2000). Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. Journal of the American Geriatrics Society, 48(7), 721–725.
Bryan, N. P., & Chapple, C. R. (2004). Frequency volume charts in the assessment and evaluation of treatment: How should we use them? European Urology, 46(5), 636–640.
Burgio, L. D., Engel, B. T., Hawkins, A., McCormick, K., Scheve, A., & Jones, L. T. (1990). A staff management system for maintaining improvements in continence with elderly nursing home residents. Journal of Applied Behavior Analysis, 23(1), 111–118.
Capezuti, E., Wagner, L., Brush, B. L., Boltz, M., Renz, S., & Secic, M. (2008). Bed and toilet height as potential environmental risk factors. Clinical Nursing Research, 17(1), 50-66.
Cardosi, R. J., Cardosi, R. P., Grendys, E. C., Jr., Fiorica, J. V., & Hoffman, M. S. (2003). Infectious urinary tract morbidity with prolonged bladder catheterization after radical hysterectomy. Am J Obstetrics & Gynecology, 189(2), 380–383; discussion 383–384.
Castelo-Branco, C., Cancelo, M. J., Villero, J., Nohales, F., & Julia, M. D. (2005). Management of postmenopausal vaginal atrophy and atrophic vaginitis. Maturitas, 52 (Suppl. 1), S46–52.
Centers for Disease Control and Prevention. (1981). Guideline for prevention of catheter-associated urinary tract infections. Retrieved July 30, 2008, from http://www.cdc.gov/NCIDOD/DHQP/ gl_catheter_assoc.html
CMS Long Term Care Journal. (2004, Oct.) Urinary incontinence—Volume II. Retrieved June 5, 2008, from http://cms.internetstreaming.com/courses/36/handouts/Agenda+UI+10-2004.doc
CMS Manual System. (2005). §483.25(d) Urinary incontinence. Retrieved April 25, 2008, from http:// www.cms.hhs.gov/transmittals/downloads/r8som.pdf
Connor, P. A., & Kooker, B. M. (1996). Nurses’ knowledge, attitudes, and practices in managing urinary incontinence in the acute care setting. Medsurg Nursing, 5(2), 87–92, 117.
Cooper, G., & Watt, E. (2003). An exploration of acute care nurses’ approach to assessment and management of people with urinary incontinence. Journal of Wound, Ostomy, and Continence Nursing, 30(6), 305–313.
Cornia, P. B., Amory, J. K., Fraser, S., Saint, S., & Lipsky, B. A. (2003). Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. American Journal of Medicine, 114(5), 404–407.
Dmochowski, R. R. (2005). Bladder outlet obstruction: Etiology and evaluation. Review in Urology, 7 (Suppl. 6), S3–S13.
DuBeau, C. E. (2005). Improving urinary incontinence in nursing home residents: Are we FIT to be tied? Journal of the American Geriatrics Society, 53(7), 1254–1256.
DuBeau, C. E. (2006). The aging lower urinary tract. Journal of Urology, 175(3 Pt 2), S11–15. Fader, M. (2003). Review of current technologies for urinary incontinence: Strengths and limitations.
Proceedings of the Institution of Mechanical Engineers [H], 217(4), 233–241.
Fernandez, H. M., Callahan, K. E., Likourezos, A., & Leipzig, R. M. (2008). House staff member awareness of older inpatients’ risks for hazards of hospitalization. Archives of Internal Medicine, 168(4), 390–396.
Fonda, D., DuBeau, C., Harari, D., Ouslander, J. G., Palmer, M. H., & Roe, B. (2005). Incontinence in the frail elderly. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.), Incontinence (Vol. 2). Paris: Health Publications Ltd.
Goode, P. S., Burgio, K. L., Redden, D. T., Markland, A., Richter, H. E., Sawyer, P., et al. (2008). Population based study of incidence and predictors of urinary incontinence in black and white older adults. Journal of Urology, 179(4), 1449–1453; discussion 1453–1444.
Balkrishnan, R., Bhosle, M. J., Camacho, F. T., & Anderson, R. T. (2006). Predictors of medication adherence and associated health care costs in an older population with overactive bladder syndrome: A longitudinal cohort study. Journal of Urology, 175(3 Pt 1), 1067–1071; discussion 1071–1072
Borrie, M. J., Campbell, K., Arcese, Z. A., Bray, J., Hart, P., Labate, T., et al. (2001). Urinary retention in patients in a geriatric rehabilitation unit: Prevalence, risk factors, and validity of bladder scan evaluation. Rehabilitation Nursing, 26(5), 187–191.
Brading, A. F. (1997). A myogenic basis for the overactive bladder. Urology, 50(6A Suppl.), 57–67; discussion 68–73.
Bradley, C. S., Zimmerman, M. B., Wang, Q., & Nygaard, I. E. (2008). Vaginal descent and pelvic floor symptoms in postmenopausal women: A longitudinal study. Obstetrics & Gynecology, 111(5), 1148–1153.
Brown, J. S., Vittinghoff, E., Wyman, J. F., Stone, K. L., Nevitt, M. C., Ensrud, K. E., et al. (2000). Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. Journal of the American Geriatrics Society, 48(7), 721–725.
Bryan, N. P., & Chapple, C. R. (2004). Frequency volume charts in the assessment and evaluation of treatment: How should we use them? European Urology, 46(5), 636–640.
Burgio, L. D., Engel, B. T., Hawkins, A., McCormick, K., Scheve, A., & Jones, L. T. (1990). A staff management system for maintaining improvements in continence with elderly nursing home residents. Journal of Applied Behavior Analysis, 23(1), 111–118.
Capezuti, E., Wagner, L., Brush, B. L., Boltz, M., Renz, S., & Secic, M. (2008). Bed and toilet height as potential environmental risk factors. Clinical Nursing Research, 17(1), 50-66.
Cardosi, R. J., Cardosi, R. P., Grendys, E. C., Jr., Fiorica, J. V., & Hoffman, M. S. (2003). Infectious urinary tract morbidity with prolonged bladder catheterization after radical hysterectomy. Am J Obstetrics & Gynecology, 189(2), 380–383; discussion 383–384.
Castelo-Branco, C., Cancelo, M. J., Villero, J., Nohales, F., & Julia, M. D. (2005). Management of postmenopausal vaginal atrophy and atrophic vaginitis. Maturitas, 52 (Suppl. 1), S46–52.
Centers for Disease Control and Prevention. (1981). Guideline for prevention of catheter-associated urinary tract infections. Retrieved July 30, 2008, from http://www.cdc.gov/NCIDOD/DHQP/ gl_catheter_assoc.html
CMS Long Term Care Journal. (2004, Oct.) Urinary incontinence—Volume II. Retrieved June 5, 2008, from http://cms.internetstreaming.com/courses/36/handouts/Agenda+UI+10-2004.doc
CMS Manual System. (2005). §483.25(d) Urinary incontinence. Retrieved April 25, 2008, from http:// www.cms.hhs.gov/transmittals/downloads/r8som.pdf
Connor, P. A., & Kooker, B. M. (1996). Nurses’ knowledge, attitudes, and practices in managing urinary incontinence in the acute care setting. Medsurg Nursing, 5(2), 87–92, 117.
Cooper, G., & Watt, E. (2003). An exploration of acute care nurses’ approach to assessment and management of people with urinary incontinence. Journal of Wound, Ostomy, and Continence Nursing, 30(6), 305–313.
Cornia, P. B., Amory, J. K., Fraser, S., Saint, S., & Lipsky, B. A. (2003). Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. American Journal of Medicine, 114(5), 404–407.
Dmochowski, R. R. (2005). Bladder outlet obstruction: Etiology and evaluation. Review in Urology, 7 (Suppl. 6), S3–S13.
DuBeau, C. E. (2005). Improving urinary incontinence in nursing home residents: Are we FIT to be tied? Journal of the American Geriatrics Society, 53(7), 1254–1256.
DuBeau, C. E. (2006). The aging lower urinary tract. Journal of Urology, 175(3 Pt 2), S11–15. Fader, M. (2003). Review of current technologies for urinary incontinence: Strengths and limitations.
Proceedings of the Institution of Mechanical Engineers [H], 217(4), 233–241.
Fernandez, H. M., Callahan, K. E., Likourezos, A., & Leipzig, R. M. (2008). House staff member awareness of older inpatients’ risks for hazards of hospitalization. Archives of Internal Medicine, 168(4), 390–396.
Fonda, D., DuBeau, C., Harari, D., Ouslander, J. G., Palmer, M. H., & Roe, B. (2005). Incontinence in the frail elderly. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.), Incontinence (Vol. 2). Paris: Health Publications Ltd.
Goode, P. S., Burgio, K. L., Redden, D. T., Markland, A., Richter, H. E., Sawyer, P., et al. (2008). Population based study of incidence and predictors of urinary incontinence in black and white older adults. Journal of Urology, 179(4), 1449–1453; discussion 1453–1444.
Lai, K. K., & Fontecchio, S. A. (2002). Use of silver-hydrogel urinary catheters on the incidence of catheter-associated urinary tract infections in hospitalized patients. American Journal of Infection Control, 30(4), 221–225.
Landi, F., Cesari, M., Onder, G., Zamboni, V., Barillaro, C., Lattanzio, F., et al. (2004). Indwelling urethral catheter and mortality in frail elderly women living in community. Neurourology and Urodynamics, 23(7), 697–701.
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