International Continence Society (ICS) 41st Annual Meeting

August 29-September 2, 2011; Glasgow, UK

Poster

Modifiable Factors Influence Risk of Double Incontinence in Nursing Home Residents

Garrett Melton

A prospective study presented in a poster session at the ICS meeting found significant racial disparities among nursing home residents who develop urinary and fecal (double) incontinence, a condition affecting as many as 60% of residents. The poster, titled Racial and Ethnic Disparities in Time to Developing Urinary and Fecal (Double) Incontinence in Nursing Home Older Adults, showed that more black nursing homes residents than anticipated had developed double incontinence within 6 months of admission, whereas fewer Asian residents than expected received a diagnosis of double incontinence during the first 6 months of their stay. The investigators performed various analyses to identify factors related to patients, facilities, and the community that might have influenced the disparities observed.

The prospective cohort included adults aged ≥65 years (mean age, 81 years) who were incontinence free when admitted to any of 452 nursing homes between 2000 and 2002; the nursing homes belonged to a national chain and spanned 29 states. According to Minimum Data Set (MDS) 2.0 assessments, the majority of residents (n=44,516) were women (68%) and non-Hispanic white (91%). Other races/ethnicities included non-Hispanic black (6%), Asian/Pacific Islander (1.3%), American Indian (0.5%), and Hispanic (1.4%). Data indicated 37% of the residents never finished high school.

The researchers defined double incontinence as documentation of fecal and urinary incontinence on a single MDS record. Black residents had the highest rates of double incontinence, at 22%, as compared with rates of 14% for Hispanics, 13% for whites and for American Indians, and 12% for Asians. In blacks, the onset of double incontinence took place a median of 127 days after admission, which was significantly earlier than the median of 158 days for Asians, 178 days for American Indians, 217 days for whites, and 239 days for Hispanics.

Relying on information from the literature and the views of clinical experts, the investigative team identified patient demographic, nursing home, and community criteria believed to increase the risk of developing double incontinence and looked for correlations with the MDS reports. Age, sex, functional deficits, comorbidities, use of restraints, and medications were resident factors affecting the time to double incontinence in white residents. Nursing home/community risk factors that influenced the development of double incontinence in whites included the proportion of patients in the nursing home with incontinence and location and staffing of the nursing home. Using findings for the white residents as a baseline for comparisons of risk for earlier onset of double incontinence among the other study subgroups, investigators reported that the proportion of the surrounding area considered urban was the most significant risk factor for earlier double incontinence in black residents (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.12-1.35) followed by the use of restraints (HR, 1.20; 95% CI, 1.07-1.34). Comparing the time to double incontinence in Asians versus whites indicated greater risk of earlier onset for Asians living essentially in the Mountain time zone (HR, 1.58; 95% CI, 1.08-2.32) and those who had to be restrained (HR, 1.28; 95% CI, 1.08-1.52).

Comparing the rates of double incontinence at any time after admission between white and black residents demonstrated higher risk for blacks having more deficits in activities of daily living (ADLs), although the difference was slight (HR, 1.05 vs 1.06, respectively). White residents were significantly more likely than black residents to develop double incontinence when >10% of residents in the facility had incontinence (HR, 1.12 vs 1.00, respectively). Communication difficulties were found to increase the risk of double incontinence for whites in comparison with Asians (HR, 1.13 vs 0.92, respectively).

Although a greater percentage of Asians remained free of double incontinence than expected based on rates reported in the literature, the difference only became statistically significant when nursing home factors (P=.018) were taken into account. The percentage of blacks who remained free of double incontinence, however, remained significantly lower than anticipated when considering resident factors alone (P<.001) and resident and nursing home factors combined (P<.001).

The authors of the study said their findings help confirm previous reports of racial and ethnic disparities in the prevalence of double incontinence among nursing home residents and indicate that resident, nursing home, and community factors all contribute to a resident’s risk. They noted that several of the factors associated with increased risk (eg, deficits in ADLs, communication, and % of coresidents with incontinence) are modifiable and suggested nursing homes target these modifiable factors to decrease rates of double incontinence and disparities between different groups of residents.

This study was funded by the National Institute of Nursing Research, National Institutes of Health.

Implementing Toilet Regimens Reduces Diaper Use in Residents

Garrett Melton

A study presented at the ICS meeting demonstrated that a program using different toileting regimes helps nursing home residents manage incontinence more effectively, allowing them to stay dry and reducing their risk of rash, related skin breakdown, and urinary tract infection (UTI). Helping residents overcome incontinence and weaning them out of diapers can also improve their self-confidence and quality of life. In addition, nursing homes that reduce incontinence rates can reduce money spent on diapers, wipes, wash water, disinfectants, hand towels, and waste disposal. A lower rate of incontinence also decreases the burden on staff, with fewer patients needing to be changed.

The 4-month project had a dual purpose: assess the ability of a toileting program to reverse incontinence in nursing home residents and train nurses working in nursing homes on handling residents with incontinence. Investigators selected 16 residents to participate who wore diapers, could communicate the need to urinate, and required only one person to assist with mobility. Most of the residents enrolled in the study had functional incontinence due to poor mobility and/or cognitive impairment.

Supervising nurses were instructed on how to perform a basic assessment of continence, determine each resident’s type of incontinence and likely causes, perform a bladder scan for urinary incontinence, and chart voiding patterns; when to refer the patient to the physician and/or rehabilitation team; and ways to implement three toileting regimens, including prompted or timed voiding or a self-scheduled toileting regimen.

To aid in establishing a toilet regimen for a particular resident, nurses charted each patient’s bladder habits for 3 days. Afterward, three residents decided to remain on diapers. At the study’s conclusion, 12 patients had been successful in ending their reliance on diapers and only one failed to make the transition to a toileting regimen. Of the 12 residents weaned off of diapers, 11 could self-schedule their toileting needs (3 with the assistance of staff) and one followed a bathroom schedule.  Early in the course of the study, four residents were discovered to have a UTI and received prescribed medication to treat the ailment. 

Residents who were able to stop using diapers reported less pruritis and developed fewer rashers. “Hence, we also reduced the potential risk for skin breakdown and pressure sores,” wrote the authors. “We also reduced the potential risk of UTI.” The program eliminated the need for 56 diaper changes each day, reducing costs and demands on nurses’ time.

The investigators concluded that toileting regimens are an effective way to help nursing home residents manage their incontinence and remain dry. “We hope that the project can be shared with staff in the other nursing homes, so that we can improve the quality of life for the seniors with functional incontinence,” said the authors.

This study was funded by the Tote Board Singapore.

Poster

Meta-analysis Suggests High Prevalence of Fecal Incontinence in Nursing Homes

Garrett Melton

A meta-analysis of several studies and articles addressing fecal incontinence (FI) in elderly nursing home patients was presented by a team of Norwegian investigators at the ICS meeting. Titled Fecal Incontinence Among Elderly Patients in Nursing Homes: a Systematic Review of Prevalence and Risk Factors, the poster pointed to a widely varying but relatively high prevalence of FI among nursing home residents. Investigators also identified several comorbid conditions that seemed to correlate with an increased risk of FI.

After searching the literature for articles related to FI in nursing home residents, investigators selected 15 studies and 16 articles deemed relevant. Of these 31 studies, only 14 reported the prevalence of FI in nursing home residents, and this ranged from 10.3% to 63.6%. The greatest concordance in prevalence was observed among a group of six studies that placed it between 40% and 55%. Researchers noted several factors that might account for the tremendous disparity in prevalence rates among the studies. For example, the studies applied different definitions of FI, with variation in the frequency of bowel movements used to diagnose the condition. Studies also varied in how they defined a nursing home. The lack of demographic details for participating residents in many of the studies led the poster authors to hypothesize that major variation in patient characteristics between studies might account for some of the discrepancy in prevalence. The meta-analysis was also limited by the differing variables and definitions outlined in the included studies.

In all, nine studies identified an increased risk of FI associated with mobility-related factors. Specifically,  loss of activities of daily living, loss of mobility or poor mobility—including confinement to a wheelchair or bed—and truncal restraints correlated with an increased overall risk (OR) of FI. Together, the nine studies observed functional disability in 47% of patients with FI. Reduced cognitive functions (eg, dementia, cognitive impairment, mental function) were identified as contributing risks for FI in seven studies. Six studies reported increased risk associated with bowel/urinary tract dysfunction. Cumulatively, 70% of patients with FI in these six studies had issues with fecal loading, 44% had acute diarrhea, and 20% had loose stool; watery stool, tube feeding, urinary incontinence, and constipation were other related risk factors for FI. Another six studies determined that conditions such as stroke, neurological disease, comorbidity, diabetes, pressure ulcers, and impaired vision increased the likelihood of a resident developing FI; nearly half (47%) of patients in these six studies had a comorbid illness. These six studies also indicated a higher prevalence of FI among men and people who are not white.

Although the meta-analysis found great variance in the prevalence rates between studies, the authors said their review “confirms the assumption that there is a high prevalence of FI among nursing home patients.” They recommended further research on FI in the nursing home population, conducting studies that apply a more consistent, coherent definition of FI and use measurement tools that have been validated.