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Introduction

Urinary incontinence, defined as the involuntary loss of urine, is a significant health problem for older adults.1,2 Urinary incontinence affects over 17 million adults in the United States and is present in up to 90% of adults living with dementia.1 Women are disproportionately affected by urinary incontinence, with up to 50% of females over age 60 experiencing incontinence at least once per week.3 As incidence of incontinence rises with age, many older adults erroneously believe that it is a normal consequence of aging.1,2 Continence requires intact lower urinary tract function, intact cognition to recognize voiding signals and override the reflex to urinate until the appropriate time and place, intact functional ability to use a toilet or commode, motivation to maintain continence, and an environment that facilitates the process.1 Common age-related physical changes that predispose patients to incontinence include decrease in bladder capacity, benign prostatic hyperplasia (BPH) in men, and menopausal loss of estrogen in women. Other risk factors include immobility, use of medications such as diuretics, anticholinergics, and calcium channel blockers, obesity, smoking, malnutrition, delirium, depression, sensory impairment, and environmental barriers.1,3

Interprofessional Assessment and Collaborative Interventions

Older adults are likely to present with either acute/transient urinary incontinence or chronic/established incontinence. Acute incontinence refers to sudden and reversible onset of involuntary urine loss. A third of older adults will develop transient incontinence while hospitalized in the acute care setting.1 Causes include delirium, untreated urinary tract infection, use of pharmaceuticals, depression, restricted mobility, and constipation. Health care providers and nurses must screen patients experiencing acute onset of urinary incontinence symptoms to identify and treat the underlying cause.1 Chronic urinary incontinence refers to the gradual and irreversible onset of involuntary urine loss in older adults. The five main types of chronic urinary incontinence include stress, urge, mixed, overflow, and functional incontinence. Stress incontinence is common among women as well as men post-prostatectomy and occurs with activities that increase intra-abdominal pressure, such as coughing, sneezing, and change in position.1,2 Urge incontinence is common among both men and women and results from detrusor muscle instability. It is associated with a strong desire to void that causes patients to “leak” on the way to the bathroom. Other signs and symptoms include urinary frequency, nocturia, and enuresis.1,2 Some patients experience both stress and urge incontinence, which is referred to as mixed incontinence.1

Overflow incontinence results from an underactive detrusor muscle and causes overdistention of the bladder and subsequent leakage of urine. Common signs and symptoms include dribbling, urinary retention, hesitancy, sensation of fullness, incomplete and bladder emptying. It is often seen in patients with benign prostatic hyperplasia (BPH) and conditions that lead to denervation of the bladder muscle, such as multiple sclerosis and diabetes mellitus.1 Lastly, functional incontinence refers to involuntary loss of urine unrelated to integrity of the urinary tract. Patients with cognitive and physical impairments who are unable to recognize the need to void or unable to make it to the bathroom may experience this type. Functional incontinence is often seen in patients experiencing changes due to illness and alterations to the environment.1 All five types of urinary incontinence significantly affect quality of life for patients.1,2 Patients with urge and functional incontinence often experience falls and fractures in rushing to make it to the bathroom. All patients with incontinence are at risk of skin irritation and infection, urinary tract infections, pressure ulcers, and limited function.Psychosocial consequences include emotional distress, depression, and social isolation.1,2

All members of the interprofessional team can assist in managing urinary incontinence in older adults. Nurses and primary care providers can play a key role in assessing patients for urinary incontinence by taking a thorough medical history, conducting a physical examination, identifying any underlying factors of incontinence, and assisting patients in keeping a bladder diary to keep track of symptoms.1,2 It is important to screen all patients for urinary incontinence as those experiencing mild symptoms may delay seeking medical assistance until symptoms begin to interfere with one’s ability to complete ADLs and live a social and independent life.2 Providers and nurses should assess patients for risk factors of urinary incontinence, including issues with mobility, use of prescription medications and alcohol, constipation, diabetes, sensory impairments, and environmental factors such as access to a toilet.2

Traditionally, interventions used in treatment of urinary incontinence have included containment strategies such as use of bedpan, urinal, commode, and absorbent pads, briefs, and sanitary napkins. While containment interventions are still used, current guidelines encourage use of more preventative interventions for older adults with urinary incontinence. Patients are instructed to avoid bladder irritants such as caffeine and acidic foods and to increase daily fluid intake. To avoid nocturia, however, patients are advised to limit fluid intake before bed.1,2 In inpatient settings, acute care providers and hospital staff should avoid use of indwelling urinary catheters whenever possible.Patients with functional type incontinence may require an elevated toilet seat, bedside commode, male/female urinal, or bedpan to assist in the act of voiding. The call bell should always be in reach for patients to call for assistance. Nurses and unlicensed assistive personnel can assist in keeping patients to a toileting schedule, including timed voiding and prompted voiding.1,2 Physical therapists can assist patients in practicing pelvic floor muscle exercises, bladder training, use of ambulation aids, and gait training to improve muscle.1,2,3  strength.1,2,3 Occupational therapists can assess patient for difficulty in completing ADLs and work with him or her to maintain independence.1,2,3

Acute and primary care providers can consult with pharmacists to consider use of certain medications that may decrease episodes of incontinence, such as anticholinergic drugs for patients with urge incontinence.1,2 The team should carefully monitor patients taking these medications, as they have the potential to cause delirium, leading to worsened cognitive function and issues of incontinence.3 When planning for discharge, the interprofessional team also needs to consider the patient’s needs at home. Home health aides can assist in adherence to bladder training regimens and minimizing episodes of incontinence.1 Visiting staff to the home, including nurses, social workers, and home health aides, can assist patient in decluttering and organizing the home environment to promote safe passage to the bathroom.1,2

Interprofessional contacts for this topic:

Primary care providers

Acute care providers

Pharmacists

Registered nurses

Physical therapists

Occupational therapists

Social workers

Unlicensed assistive personnel

Home health aids

Link to the following evidence-based protocols:

Assessing cognition

Delirium

Dementia

Function

Prevention of catheter-associated urinary tract infection

Urinary incontinence

References

1Dowling-Castronovo, A., & Bradway, C. (2012). Urinary incontinence. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 363-387). New York, NY: Springer Publishing Company.

2Sims, J., Browning, C., Lundgren-Lindquist, B., & Kendig, H. (2011). Urinary incontinence in a community sample of older adults: Prevalence and impact on quality of life. Disability and Rehabilitation, 33(15-16), 1389-1398.

3Huang, A. J., Brown, J. S., Thom, D. H., Fink, H. A., Yaffe, K., & Study of Osteoporotic Fractures Research Group. (2007). Urinary incontinence in older community-dwelling women: The role of cognitive and physical function decline. Obstetrics & Gynecology, 109(4), 909-916.