T L C Continence A Matter of Dignity

T L C Continence: A Matter of Dignity Causes, Signs and Prevention By L Marie Mangino, MSN, CRNP, GNP-BC T President, Vincent Healthcare, Inc. C Wendy W. Fox, MOT, OTR/L Assistant Professor of Occupational Therapy University of the Sciences, Philadelphia PA Jennifer A. Reinhold, BA, Pharm. D, BCPS Assistant Professor of Clinical Pharmacy University of the Sciences in Philadelphia Geriatric Education Center of Greater Philadelphia

T L C Acknowledgements Appearing in Video: Name L T C Appearing as Bob Swensen………. Mr. Banks Ruth Alpert…………Mrs. Banks Susaye Lawson…… Susaye Nate Lazowick……. Mr. Williams Kevin Brown……… Carl, DCSW Dinnie Childs………Piano Player Clarese Herbert……Mr. William’s friend Man at Piano………Arjun Bhojwani Nancy Web…………Mrs. Powell Eric Stewart………. Mike, grandson Ruth Livikoff………Ruth, DCSW Name Appearing as Dick Brown………………Mr. Clark Deanna Penn……………. Supervisor Sangeeta Bhojwani……. Trainee Roby Jacobs……………. . Daughter Charlene Duff……………Shopper, Gift Shop Sheila Mitchell-Ayers…Shopper, Gift Shop Marie Mangino…………. Trainer, as herself Tanisha Jones……………Testimonial Julie Cohlmer……………. Testimonial Geriatric Education Center of Greater Philadelphia

T L C Special thanks to: L T C • Henrietta Roberts and Sandy Bailey, of Stapeley in Germantown for coordination of video shoot • All the residents and staff of Stapeley in Germantown, for their participation and for permitting video production. • Raybourn Rusk Productions Geriatric Education Center of Greater Philadelphia

T L C Play video segment titled, “ 01 Introduction. mpg” L T C Geriatric Education Center of Greater Philadelphia

T L C Urinary Incontinence (UI) Defined L T C UI is simply defined as the involuntary or inappropriate loss of urine. In other words, incontinence is urine loss which happens when the person doesn’t want it to or doesn’t know it’s happening. Geriatric Education Center of Greater Philadelphia

Learning Objectives T L C L T C At the end of this program you will be able to: q List the common causes of urinary incontinence (UI) q Describe the potentially serious effects of not treating UI q Recognize signs of a urinary tract infection q Discuss effective ways to prevent or reduce episodes of UI q Enhance the dignity of those in your care Geriatric Education Center of Greater Philadelphia

Prevalence of UI T L C q More thank 13 million Americans L T C have UI q 85% of them are women q 37% of persons over 65 and living in the community have UI q 53% of homebound have UI q 30 -77% of NH residents have UI In 8 of 10 cases symptoms can be improved and in some cases function restored. Geriatric Education Center of Greater Philadelphia

T L C The Facts about UI Continence is normal; Incontinence is not q Normal aging does not cause incontinence q When continence is impaired, many simple things can be done to restore or improve function q L T C Mrs. Mendoza Geriatric Education Center of Greater Philadelphia

T L C Caring for UI is Important Because: q Untreated or under-treated UI can cause: § L § T C § Skin breakdown and infection Falls and injuries Sleep disturbance Mr. Phillips Geriatric Education Center of Greater Philadelphia

Caring for UI is Important Because: T L C q Untreated or under treated UI can cause: § L § T C § Depression/social withdrawal Loss of dignity/lower quality of life UTIs (urinary tract infections) hospitalization death Geriatric Education Center of Greater Philadelphia

T L C Left Kidney Right Kidney Ureters L T C Structure of the Urinary Tract System Urethra Bladder wall muscle by Nicole Mangino 2004 Geriatric Education Center of Greater Philadelphia

T L C Contributors to UI: Age-Related Changes q Overactive bladder muscle q Enlarged prostate (BPH) q Atrophic vaginitis and L T C urethritis (occurs after menopause) q Reduced bladder capacity q Increased post-void residual (PVR) Geriatric Education Center of Greater Philadelphia

T L C Contributors to UI: Injury and Disease q Diabetes q Damage to the: q Brain L q Spinal Cord T q Bladder C q Short term use of an indwelling catheter during acute illness Mrs. Banks Geriatric Education Center of Greater Philadelphia

T L C Contributors to UI: Limitations in Function q Ambulation q Dressing L q Fear of falling T C q Choice Mr. Williams Geriatric Education Center of Greater Philadelphia

Contributors to UI: Dietary Factors T L C q Artificial L T C sweeteners q Caffeine q Alcohol q Acidic Foods Mrs. Powell Geriatric Education Center of Greater Philadelphia

Contributors to UI: Medications T L C Anticholinergics : Can affect the bladder’s ability to empty q Diuretics (water pills): Cause extra urine production q Cold medicines: Can affect the bladder’s ability to empty q Pain medicines: Can cause constipation and fecal impaction q L T C Geriatric Education Center of Greater Philadelphia

T L C Contributors to UI Hydration & Physical Conditions q Not enough fluid q Too much fluid L q Fecal impaction T C q Acute confusion q Too much alcohol or caffeine q Infections/Medical illness Geriatric Education Center of Greater Philadelphia

T L C UTI Symptoms in the Older Adult q Increased frequency q Increased urgency q New or increased UI L q Urine odor or cloudiness T C q Blood in the urine q Fever or chills q Change in mental status Geriatric Education Center of Greater Philadelphia

Acute Changes in Mental Status that may indicate UTI T L C q Sleepiness q Irritability or agitation L q Lethargy T C q New or increased confusion Mr. Green Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do for Older Adults with UI q Keep a log of UI L events q Monitor toileting T C Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do for Older Adults with UI q Determine frequency L T C of need q Develop a schedule and assist to toilet q Consider recent medication change Geriatric Education Center of Greater Philadelphia

T L C Play video segment titled, “ 02 Mrs. Banks. mpg” L T C Geriatric Education Center of Greater Philadelphia

Things You can Do: Scheduling T L C Log actual number of “accidents” or “urinations” q Based on log results - develop schedule q Establishing and following a schedule can give a person confidence to do other things q Prompt and assist q Praise the effort q L T C Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do Encourage change in diet (gradually reducing and then eliminating caffeine, alcohol, sweeteners and acidic foods) q Avoid over the counter medications that can cause constipation or make continence more difficult q L T C Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do q L T C Assist as needed to: § Get to the bathroom or commode safely § Remove clothing § Make urinals (male and female) available as well as bed pans § Position urinal or bedpan § Assist w/ pericare and appropriate products and redressing Geriatric Education Center of Greater Philadelphia

T L C Play video segment titled, “ 03 Mr. Williams. mpg” L T C Geriatric Education Center of Greater Philadelphia

Mr. Williams’ Challenge T L C q Arthritis q Personal L T C embarrassment q Effect on family q Clothing with elastic or Velcro closures Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do • Establish safe bathroom setup – Use of grab bars and/or a raised toilet seat, 3 -in-1 commode L T C – Observe for good hygiene – Assist if needed with hygiene Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do q Make urinals available q Prompt (suggest, encourage L T C and remind) to toilet q Compliment effort and success q Change if incontinent Mr. Samson Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do “JIC” • For outings…. Be prepared! – Take a “JIC” bag – Just In Case L T C • • • Extra set of clothes Incontinence products (briefs, liners, underwear) Gloves, moist wipes, hand sanitizer Absorbent pads to protect furniture Air deodorizer Plastic bag • Being prepared reduces anxiety for both the client and the caregiver! Geriatric Education Center of Greater Philadelphia

T L C Skin Care To prevent skin breakdown: q q L T C q q Work towards improved continence Promptly change absorbent undergarments and clean perineum and buttocks Use a skin barrier Promptly report any change in skin Geriatric Education Center of Greater Philadelphia

T L C Product Use for UI q q Least restrictive Most dignified Individual product preference q Proper fit § Regular underwear w/ liner § Pull-up § Brief (adult absorbent product) § Proper fit ensures best protection and is most cost effective! q L T C Geriatric Education Center of Greater Philadelphia

T L C Things You Can Do • Simple clothing changes make toileting a lot easier! L T C – Velcro closures on shirts/pants/shoes makes on/off less effortful – Elastic waistbands and roomier fit ease up/down of pants – Add rings onto zippers Geriatric Education Center of Greater Philadelphia

T L C Final Case Scenario • • L T C Ms. Hill has rheumatoid arthritis with severe deformities of her hands She has difficulty with such things as door knobs and buttons on her clothes Mrs. Hill Geriatric Education Center of Greater Philadelphia

Learning Objectives Review T L C Can you now: q q L q T C q q List the common causes of urinary incontinence (UI) Describe the potentially serious effects of not treating UI Recognize signs of a urinary tract infection Discuss effective ways to prevent or reduce episodes of UI List ways to enhance the dignity of those in your care Geriatric Education Center of Greater Philadelphia

Special Thanks To: T L C Christine Bradway, Ph. D, CRNP, FAAN Associate Professor of Gerontologic Nursing University of Pennsylvania School of Nursing L T C Mary Ann Forciea, MD Clinical Associate Professor of Medicine Director, Primary Care Services University of Pennsylvania Health Systems Nicole Mangino Illustrator Geriatric Education Center of Greater Philadelphia

T L C References and Resources • American Medical Directors Association. (2012). Urinary Incontinence in the Long Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA. • Du. Beau, C. E. , Kuchel, G. A. , Johnson. T. , Palmer, M. H. , Wagg, A. Incontinence in the frail elderly. In Abrams, P, Cardozo, L, Khoury, S, Wein, A. (2009). 4 th International Consultation on Incontinence. Health Publication Ltd. 9631024. L T C • Du. Beau CE, Simon SE, Morris JN. The effect of urinary incontinence on quality of life in older nursing home residents. J Am Geriatr Soc 2006; 54: 1325 -33. • Fink HA, Taylor BC, Tacklind JW, Rutks IR, Wilt TJ. Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Mayo Clin Proc 2008; 83: 1332 -43 Geriatric Education Center of Greater Philadelphia

T L C References and Resources • • L T Genao, L. & Buhr, G. T. Urinary tract infections in older adults residing in long-term care facilities. Annals of Long-Term Care: Clinical Care and Aging. 2012; 20(4): 33 -38. Hagglund, D. (2010). A systematic literature review of incontinence care for persons with dementia: the research evidence. Journal of Clinical Nursing. 2010; 19, 303 -312. • Kraus SR. Bavendam T. Brake T. Griebling TL. Vulnerable elderly patients and overactive bladder syndrome. Drugs & Aging. 2010; 27(9): 697 -713. C Geriatric Education Center of Greater Philadelphia

T L C References and Resources • • L T Landefeld CS, Bowers BJ, Feld AD, et al. National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med 2008; 148: 449 -58. Lee, S. Y. , Phanumus D. & Fields S. D. Urinary incontinence: a primary care guide to managing acute and chronic symptoms in older adults. Geriatrics 2000; 55(11): 65 -72. Matthews, S. J. & Lancaster, J. W. Urinary tract infections in the elderly population. The American Journal of Geriatric Pharmacotherapy 2011; 9: 286 -309. • C • Newman, D. K. , & Wein, A. J. Managing and treating urinary incontinence. 2 nd ed. 2009; Baltimore, MD: Health Professions Press. Geriatric Education Center of Greater Philadelphia

T L C References and Resources • • L T C Offermans, MP, Du Moulin MF, Hamers JP, Dassen T, Halfens RJ. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009; 28: 288 -94. Saliba D, Solomon D. Rubenstein L. Young R. Schnelle J. Roth C. Wenger N. Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents. Journal of the American Medical Directors Association 2005; 6(3 Suppl): S 50 -9, 2005. Geriatric Education Center of Greater Philadelphia

T L C References and Resources Web sites: Collaborative to Support Urinary Incontinence and Women’s Health www. stress. UI. org National Association for Continence: www. nafc. org L T C Australian Government Department of Health and Aging http: //www. bladderbowel. gov. au/all/bladderproblem s. htm National Kidney and Urologic Diseases Information Clearing House http: //kidney. niddk. nih. gov/index. aspx Geriatric Education Center of Greater Philadelphia