Urinary incontinence (UI) is a common condition in elderly nursing home (NH) residents. It is associated with a poor quality of life (QOL) among community-dwelling sufferers in everyday life Citation[1]. In a NH, where residents are already limited in a variety of activities, one would assume that UI would be associated with poorer QOL because of both the burden it presents and its correlation with other associated diseases. UI in the NH differs from that in the community. Much of it is situational rather than physiologically or anatomically based. Underlying problems of confusion and immobility often lead to UI. Hence, the treatment approaches should be different.
Both qualitative interviews about the adverse effect of UI on the wellbeing of affected residents in NHs and quantitative studies showed adverse effects of UI on QOL Citation[2]. Using the Social Engagement Scale as a proxy measure of QOL in NHs, DuBeau et al. found that UI decreased QOL in older residents with moderate cognitive and functional impairment, and new or worsening UI was strongly correlated with worse QOL Citation[3]. Using inverse probability weighting based on propensity scores adjustments to reduce selection bias, we found that although UI was not associated with older NH residents’ self-reported overall QOL, it lowered the QOL domains of dignity, autonomy and mood Citation[4]. These findings may be explained by MacDonald‘s and Butler‘s qualitative study. The inability to control urination and the feeling of embarrassment and regression to childhood led to loss of dignity, independence and decision-making power in UI care Citation[2]. The relationship between UI and depressive symptoms appeared to be particularly strong Citation[5]. The failure to find a significant relationship between UI and overall QOL may be due to the insensitivity of the general QOL questionnaire to detect small, but important, changes attributed to UI. To gain a complete picture of QOL in UI, it is better to combine a generic QOL measure with a UI-specific QOL measure (e.g., Incontinence QOL questionnaire).
UI is managed differently in NHs compared with the community. Behavioral therapies, such as prompted voiding Citation[6], habit training Citation[7] and exercise programs Citation[8], are effective in reducing UI. However, these approaches are not widely used since they are considered to be too labor intensive and expensive Citation[3]. Even when they have been shown to be effective in studies, they are discontinued at the end of the study Citation[9]. Instead, the vast majority of UI residents in NHs use absorbent products Citation[10].
What are the barriers to managing UI in NHs?
UI is a neglected geriatric syndrome in NHs. The widespread belief about UI is that it is a natural, inevitable and normal part of aging. As a result, it is often left unevaluated and managed. Only 37% of cases with UI at admission had documentation that clinicians were aware of it and only 5% of cases developing UI during their stay in NH were reported to clinicians Citation[10]. Physicians, geriatric nurse practitioners and directors of nursing are less likely to evaluate and manage UI compared with five other geriatric syndromes (i.e., behavioral symptoms of dementia, pain, falls, delirium and unintended weight loss). Moreover, they perceive UI to have less impact on QOL compared with the other syndromes Citation[11]. By contrast, nursing assistants, who were most frequently involved in evaluating and managing UI, rated UI‘s effect on QOL second only to pain Citation[11].
The success of some behavioral therapies for UI depends heavily on residents’ ability to understand and remember instructions, and to go to a toilet independently Citation[12]. However, NH residents’ cognitive and mobility impairments require NH staff to provide frequent instructions and assistance to access toilets. Although prompted voiding is effective, it must contend with mobility problems and resident resistance.
Behavioral therapies are labor intensive and costly, especially compared with absorbent products. Although residents and their family members expressed preference for and satisfaction with behavioral therapies, translating these benefits into practice will be challenging and current staffing in NHs is inadequate to provide it Citation[8,9,13]. These potentially effective therapies are rarely or never tried Citation[10]. The small savings in laundry and supplies from the benefits of behavioral therapies do not offset the costs of labor involved in these behavioral therapies Citation[3,14].
The use of pharmacological therapy in NHs is quite low; only 8.7% of residents with severe UI were treated with drugs Citation[15]. The limited use of drugs may be a good thing. They are not very effective and have potentially serious side effects Citation[16]. The typical drugs used to treat UI have anticholinergic properties, which are associated with cognitive decline; older residents with mild cognitive impairment or dementia are particularly sensitive to these side effects Citation[17]. Physicians perceived the greatest barriers to improving UI care to be the potential drug adverse effects and drug therapy alone is not effective Citation[11]. Drugs may not be the solution; they may be part of the problem. One study found that most UI residents took at least one drug that could contribute to incontinence, such as diuretics, psychotropic agents and drugs with autonomic effects Citation[12].
Despite the existing barriers, appropriate management of UI can certainly help reverse suffering and improve residents’ QOL. The appropriate outcomes should be set for incontinence care. The natural course of chronic conditions is deterioration and success care must be defined as “doing better than would be expected otherwise” Citation[18]. Preventing or slowing the speed of UI decline may be a reasonable achievement for residents in NHs as their age and dependency increases. Moreover, the objective reduction in urine leakage should not be considered as the only primary outcome for UI residents. Improvement in QOL should also be taken into account, especially preserving residents’ dignity and autonomy. The effect of UI on QOL should be part of calculating the cost–benefit of UI therapies. Urine leakage can be valuable in identifying the efficacy of an intervention, but it is an intermediate outcome, not a patient-centered outcome. Indeed, an intervention might improve QOL with little effect on urine leakage.
If one cannot make a strong economic case for effectively treating UI in the NH, it may be necessary to create incentives to do so through some variant of pay-for-performance. UI is reflected in quality measures, but only in a modest way. Quality indicators reflect the rates of UI and whether there is a treatment plan, but not the appropriateness of that plan. Although there are quality indicators based around UI, there is no direct incentive to reduce the prevalence or the consequences.
Doctors, nurses and administrators share a responsibility for improving UI care and residents’ QOL, but they would be more likely to take active steps if they felt such an investment was rewarded. NH staff should identify, evaluate and manage UI more aggressively. Active interdisciplinary collaboration should be initiated to comprehensively assess residents with UI at admission or new UI before it gets worse or develops complications. In order to design a resident-centered care plan, toileting assistance should be tried for several days, along with precise documenting to detect UI residents’ responses and preferences. The care plan also needs to take into account UI residents’ cognitive and mobility impairments and the drugs they are taking. Changing long-held beliefs that UI is normal for elder NH residents and ongoing education and training is also necessary to promote UI management. Nurses should take a central role in teamwork to address stakeholders’ discrepancies, providing feedback, presenting achieved performance and suggesting changes in the care plan; but attending physicians and medical directors also have a responsibility. Furthermore, more studies are needed to investigate and identify UI residents who will most likely benefit from interventions. The NH staff could target this subgroup of residents to make the intervention more efficient. Limited staffing resources should not be an excuse for not providing appropriate care for UI residents, as even small incremental improvements in incontinence can contribute to the self-esteem and comfort of a resident Citation[19].
Voluntary control over bladder emptying is a dignity issue; dignity is a human right. NHs present all sorts of threats to dignity. Preserving dignity should be at the center of all clinical and research efforts to provide appropriate assessment and management for UI in NHs. Thus, UI residents’ QOL will ultimately be improved.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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