The process begins with a review of physical, psychological, and social health, and includes consideration of functional status, quality of life, and goals of care. The nurse continence advisor, the pelvic floor physiotherapist, and the geriatrician all play important roles in the management of urinary and fecal incontinence in older patients. Other specialists, such as occupational therapists and general physiotherapists, are involved as needed to assist patients with dexterity and mobility issues that may be contributing to incontinence. With the number of Canadians older than 65 expected to increase, more geriatric continence clinics will be needed.
Urinary and fecal incontinence are very common in the geriatric population, yet many patients and health care practitioners wrongly consider incontinence a normal part of aging. The multidisciplinary team is essential to the practice of geriatric medicine. Without treatment, urinary and fecal incontinence can lead to significant complications, including falls, pressure ulcers, and depression. Despite the risks posed by incontinence, there are surprisingly few continence clinics with a geriatric medicine focus, and more are needed.
As this segment of the population grows, assessment and management of incontinence will become increasingly important, especially for frail older adults. These very complex patients often have multifactorial incontinence due to nongenitourinary conditions such as dementia, mobility decline, poor dexterity, and polypharmacy. Such patients may not tolerate extensive urological investigations, and frailty is a known predictor of postoperative complications after urological procedures. Older adults require an incontinence assessment that includes a review of physical, psychological, and social health.
Functional status, quality of life, and goals of care must also be considered. Quality of life for older patients can be improved with the help of a nurse continence advisor NCA , a pelvic floor physiotherapist, a geriatrician, and other health professionals skilled in the assessment, diagnosis, and management of urinary and fecal incontinence. The nurse continence advisor The nurse continence advisor is a registered nurse who has recognized education, training, and certification in continence management. The NCA focuses on conservative and holistic strategies for managing incontinence and related symptoms, including urinary urgency, frequency, and nocturia, and fecal incontinence and constipation.
The NCA assesses patients using a structured approach. To begin the assessment, the NCA obtains a detailed incontinence history, including storage symptoms frequency, urgency, nocturia and voiding symptoms hesitancy, intermittency, poor flow, dribbling, and sensation of incomplete emptying.
The NCA also spends time reviewing the amount and type of fluid intake, bowel elimination history, medical history, and medications. Lastly, the NCA assesses functional and cognitive ability, and asks questions about containment product use and environmental barriers to continence, as these can be contributing causes of incontinence.
Urinary and fecal incontinence can be easily treated in many cases using conservative management alone.
Simple lifestyle strategies such as weight loss, adequate fluid intake and appropriate timing of fluids, and dietary change to ensure adequate fibre intake can all help achieve continence. Other dietary changes that may be considered include avoiding excess caffeine, alcohol, artificial sweeteners, and concentrated sugars. Behavioral strategies can also help reduce incontinence. These include practising urge suppression and bladder retraining techniques, using appropriate containment products, managing constipation, and strengthening pelvic floor muscles.
In patients with significant cognitive impairment who have difficulty using behavioral strategies, prompted or timed voiding is often helpful.
Although each patient is an individual with unique symptoms, the same structured assessment and management strategies are used for both male and female patients. Quality of life is impacted by incontinence and is a key focus of the NCA. Fear of embarrassment can lead the older adult to avoid social situations and is associated with low self-esteem, isolation, and a reduction in physical activity. The pelvic floor physiotherapist The pelvic floor physiotherapist addresses the neuromusculoskeletal aspect of continence management.
Pelvic floor muscle function is influenced by dural and peripheral neural mobility the ability of nerves to move within tissues , dynamic stabilization of the trunk, proper posture, synchronous breathing, and abdominal muscle recruitment patterns. This differs from impingement, where the nerve cannot move at all.
A Multidisciplinary Approach to Incontinence Management
Tethering will alter the recruitment pattern of the muscles innervated by that nerve or the excursion of the surrounding muscles. This will in turn affect the movement of the involved bony structures of the lumbar spine or pelvis, thereby altering the attachment of the pelvic floor muscles or the synergies required for function. The assessment begins with a detailed medical and obstetrical history to help establish causes of neural tethering affecting muscle function.
- Lesson Plans The Doorbell Rang.
- Multidisciplinary care of urinary incontinence : a handbook for health professionals.
- Magics Heart (The Núminway Chronicles Book 1).
- Pediatric Voiding Improvement Program | Johns Hopkins Children’s Center?
- Assessment Options for Incontinence.
Low back and pelvic pain, which are common in older patients, have long been associated with incontinence. Along with factors affecting the pelvic floor, the physiotherapist will consider other functional factors that can affect continence in older adults. The patient must be able to get to the bathroom safely; therefore, gait speed, balance reactions, and stamina need to be assessed. The physiotherapist will also need to consider the ability of the patient to undo buttons and zippers, pull down pants, and sit on the toilet, which will depend on hip mobility and upper extremity dexterity and strength.
During the physical examination, the physiotherapist will assess vaginal and rectal muscle recruitment patterns the successive activation of muscles to increase the strength of contraction , as well as the contraction and relaxation capacity of each individual component of the levator ani, striated rectal, and urogenital diaphragm muscles.
This process involves looking for restrictions produced by adhesions or reduced neural mobility. The impact of the contraction on organ prolapse lift and on the firmness of the rectovaginal septum is considered, as well as possible fascial damage, avulsion, or ligamentous damage. Next, the strength, speed, and timing of pelvic floor muscle contraction are assessed. This is done at rest, with cough and Valsalva maneuver testing, and during functional activities such as a one-leg stand, squat, walking, lunging, or any physical activity that the patient does regularly.
Imaging with 2D ultrasonography may be useful to assess abdominal recruitment pattern, diastasis, and levator ani excursion and activity during cough and Valsalva maneuver testing. Biofeedback can be used to assess electromyographic activity of the muscles and may help those with pelvic floor overactivity learn how to relax the pelvic floor muscles. Limitations of biofeedback include an inability to differentiate between eccentric and concentric contraction of the levator ani, and the lack of sensitivity of current probes in isolating the levator ani from adjacent muscle groups.
Education is provided about the effect of pelvic floor muscle activity, posture, and breathing pattern on incontinence, and the importance of compliance to the exercise program is reinforced. Pelvic floor physiotherapy, especially for geriatric patients, requires multiple visits as muscle strengthening and modification of muscle coordination takes time. For the average patient, treatment over a minimum of 3 months is often needed to obtain meaningful results.
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This is particularly important in frail older adults who are more likely to have chronic conditions that affect bladder and bowel function. For instance, postmenopausal women with diabetes have a 2. Polypharmacy and inappropriate prescribing are major causes of morbidity in older men and women, and are important causes of incontinence. Culprit medications for urinary incontinence commonly seen in the medication lists of older adults include diuretics, calcium channel blockers, selective serotonin reuptake inhibitors, and cholinesterase inhibitors.
Additionally, drugs that cause peripheral edema, such as gabapentin and nonsteroidal anti-inflammatory drugs, can cause nocturnal polyuria and nocturia, while angiotensin converting enzyme inhibitors may provoke a cough that exacerbates stress incontinence. Fecal incontinence may occur with diarrhea-causing medications such as antibiotics, metformin, and cholinesterase inhibitors. It is also important to remember that any medication that causes sedation, confusion, and mobility impairment in elderly patients, such as benzodiazapines, antipsychotics, and histamine receptor antagonists, may lead to an inability to toilet effectively and can therefore contribute to urinary or fecal incontinence.
Observing the patient undo zippers and buttons can identify problems with dexterity that may be impeding the ability to toilet. Examining the perineum with the patient in the lateral decubitus position will permit identification of erythema and skin breakdown due to constant moisture, perianal lesions, and hemorrhoids that can occur with chronic constipation and excessive straining. Sacral nerve sensation can be tested to screen for a neurological cause of incontinence and the anal wink can be elicited. A digital rectal exam should be performed to look for impacted stool, test anal contraction strength, and, in men, determine prostate size and consistency.
We have a dedicated site for Germany. Multidisciplinary Care of Urinary Incontinence - a Handbook for Health Professionals effectively uses a multidisciplinary approach to assist health professionals in their care of patients with urinary incontinence. It is recognized that the best outcomes are achieved by a multidisciplinary team approach especially with regard to complex cases and care of the elderly.
This book is written by expert authors from around the world with a wealth of experience in conducting clinics on pelvic floor, aged care voiding dysfunction and neuro-rehabilitation. The text is illustrated throughout and contains case-studies with input and practical tips from the different health disciplines at each point.
Urinary | Urinary Incontinence | Urination
Each chapter concludes with a list of seminal publications and web-based resources to assist the reader in the clinical environment. Multidisciplinary Care of Urinary Incontinence - a Handbook for Health Professionals is of benefit to medical and allied health disciplines including family physicians, nurses, urologists, gynecologists, physiotherapists, geriatricians, neurologists and rehabilitation specialists.
The experimental group received 50 minutes of PFMT, three times per week for six weeks, while the control group only received basic education around the pathophysiology of UI and the function of the pelvic floor muscles. In all outcome measures, results significantly favoured the intervention over the control group post-MSVP results: It was considered that practice leaned towards the use of containment techniques with little emphasis placed on active bladder rehabilitation.
Formal educational sessions were provided to the MDT to explain the rationale for the QIP and how it was to be implemented. Audits of compliance were undertaken pre-intervention and then at four and eight months after the intervention with calculation of the percentage of patients completing urinalysis, bladder diaries and SVP use Table 1.
These findings suggest that using a PDSA methodology to improve post-stroke UI management may lead to a trend in adherence to national stroke guidelines. Although these results were not powered to demonstrate the effectiveness of the intervention, given the negative impact post-UI has on patients, 7,8,9,10 and the growing body of evidence supporting the use of structured assessments and assignment to specific voiding programmes, 15,16,17 its continued use its warranted.
In conclusion, UI is a common complication of stroke that is primarily managed conservatively.
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