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Introduction

Fecal incontinence (FI), defined as soiling of underwear, clothing, or bedding several times a month or more, is a common and distressing health problem for older adults.1,2 FI affects 1 in 5 older people over age 65, with adults over age 80 reporting more frequent leakage and greater soiling than younger age groups.1,3,4 While many adults in the community suffer from fecal incontinence, prevalence of FI is highest in the acute hospital and long-term care setting.3 Men and women are equally affected.1,2,3 Older adults suffering from fecal incontinence are often reluctant to seek help due to embarrassment and perceived lack of effective treatment.2  Frequently, patients only seek help when symptoms become disabling or bothersome, which can negatively impact daily activities, relationships, and quality of life.1,2,3  For many older adults, fecal incontinence is a distressing and social isolating disease that leads to increased risk of morbidity, mortality, and dependency.3 It is a common triggering event for institutionalization of older adults in the United States.1,2,3,4

There is a strong association between fecal incontinence and increasing age. Adults over age 85 are at particularly high risk, as are frail older adults living in long term care institutions.Frailty, defined by having multiple comorbid chronic illnesses and physical limitations, is a significant risk factor for FI.3 Patients with comorbid conditions such as obesity, stroke, diabetes mellitus, dementia, neurological disease, depression, anxiety, and limited physical ability are at increased risk of incontinence episodes.2,3,4 Individuals with sphincter or pelvic floor damage and females with a history of childbirth are at risk due to changes in anatomical integrity.1,3 Inflammatory bowel disease, irritable bowel syndrome, constipation, and diarrhea may also cause symptoms of incontinence.1 Use of certain medications, including opioids, tricyclic antidepressants, hypnotics, anticonvulsants, and anti-Parkinsonian medications, is associated with higher rates of fecal incontinence.4 Individuals with physical or mental impairments may be sensitive to changes in the physical or social environment that interfere with ability to maintain continence, such as compromised access to toilets, clothes that are difficult to manipulate in a hurry, and caregivers who are overworked or insensitive to patient’s toileting needs.3 To complicate matters, over two thirds of patients with fecal incontinence have comorbid urinary incontinence, leading to more frequent episodes and increased strain on patient and caregiver.2,3

Interprofessional Assessment and Collaborative Interventions

Primary care providers can play a key role in addressing fecal incontinence early to prevent worsening of symptoms and eventual disability.1,3 Less than one quarter of patients with fecal incontinence have discussed the issue with their primary care provider, and many physicians and nurse practitioners do not regularly enquire about these symptoms.2,4 Present guidelines stress the importance of establishing baseline bowel continence status for patients over age 65 in all settings by direct questioning and direct observation. Individuals over age 80 and those with impaired mobility, impaired cognition, chronic disease, and neurological impairment should be monitored closely for onset of symptoms.2,3 Many health care professionals and patients alike fail to recognize and report fecal incontinence due to the belief that FI is a normal part of aging.3 Older adults may also be reluctant to volunteer these symptoms to their provider for social or cultural reasons, or for fear that no treatment exists to ease symptoms.3 While many individuals perceive incontinence to be an issue for women, male patients should also be assessed regularly. This issue often receives little attention and the level of unmet need for assessment and treatment in this population is high.1

For patients presenting with fecal incontinence, severity of symptoms should be assessed by determining the frequency of leakage, degree of soiling, consistency of stool leaked, and use of pads. While there is currently no agreed upon threshold to determine whether incontinence is “clinically significant,” leakage is typically self-reported as any, yearly, monthly, or weekly. For clinicians, infrequent leakage tends to suggest bouts of acute illness rather than a chronic condition of incontinence. It is important that nurses and health care providers complete a thorough history and physical to determine underlying causes of fecal incontinence. Pharmacists can assist in compiling a careful medication history and determining whether symptoms are due in part to gastrointestinal side effects of medications.1,3

Current guidelines advise targeting treatment interventions for patients who report clinically significant symptoms that have an impact on quality of life.1,3 All interventions will need to be tailored to underlying etiology of fecal incontinence to improve symptoms and overall quality of life. FI is considered the result of a complex combination of disordered anatomy and physiology, gut motility, stool consistency, emotional and psychological status, and environmental factors. As such, most patients receive a comprehensive approach to care addressing diet, medications, physical activity, and bowel habits. Nurses and providers can assist patients in implementing a structured daily exercise program, combined with increased fluid intake and frequent toileting opportunities, to improve incontinence. The team should work to establish a bowel management program to promote a more predictable pattern of bowel evacuation. Unlicensed assistive personal and caregivers can facilitate adherence to a regular toileting schedule. Lifestyle modifications, such as smoking cessation, can also help to reduce symptoms.3

Registered dietitians can advise patients in making changes to diet, such as increasing intake of fiber, to ease symptoms and maintain adequate nutrition. Anti-motility medications such as loperamide (Immodium) or laxatives to treat “overflow incontinence” from fecal impaction may be added to patient’s medication regimen in consultation with pharmacists. Providers, nurses, and physical therapists can educate patient to exercise the anal sphincter and pelvic floor muscles regularly to lessen frequency of episodes. In severe cases of physical defect, such as rectal prolapse, surgical consultation may be required to address symptoms of incontinence.3 Seeing as fecal incontinence can be emotionally distressing for both patients and caregivers, it is important that hospital social workers and psychologists work with families to effectively manage symptoms, connect with community resources, and access respite care as needed to prevent institutionalization.1,2

Interprofessional contacts for this topic:

Primary care providers

Acute care providers

Registered nurses

Pharmacists

Physical therapists

Registered dietitians

Surgeons

Social workers

Psychologists

Unlicensed assistive personnel

Link to the following evidence-based protocols:

Age-related changes

Family caregiving

Fecal incontinence

Frailty and its complications for care

Elder mistreatment and abuse

References

1Perry, S., Shaw, C., McGrother, C., Matthews, R. J., Assassa, R. P., Dallosso, H., ... & Castleden, C. M. (2002). Prevalence of fecal incontinence in adults aged 40 years or more living in the community. Gut, 50(4), 480-484.

2Edwards, N. I., & Jones, D. (2001). The prevalence of fecal incontinence in older people living at home. Age and Ageing, 30(6), 503-507.

3Norton, C., Whitehead, W. E., Bliss, D. Z., Harari, D., & Lang, J. (2010). Management of fecal incontinence in adults. Neurourology and Urodynamics, 29(1), 199-206.

4Quander, C. R., Morris, M. C., Melson, J., Bienias, J. L., & Evans, D. A. (2005). Prevalence of and factors associated with fecal incontinence in a large community study of older individuals. The American Journal of Gastroenterology, 100(4), 905-909.