Treating Urinary Incontinence in the Geriatric Population
By Kailash Sahoo
Urinary Incontinence affects approximately 13 million Americans, at least 1.5 million of them nursing home residents. For non-institutionalized persons older than 60 years of age, the prevalence ranges from 15 percent to 35 percent, with women having twice the incontinence prevalence of men. Although incontinence generally is considered a geriatric problem, it also occurs in healthy middle-aged women at a rate as high as 30 percent.
As an occupational therapist, I am amazed by the results I get treating incontinence. The treatment is effective in 80 percent of my patients.
Urinary Incontinence is defined as involuntary loss of urine that is sufficient to be a problem. Urinary Incontinence can be caused by factors affecting either the anatomy or the physiology of the lower urinary tract or both, as well as other factors. Risk factors are immobility, low fluid intake, pelvic muscle weakness, stroke, diabetes, and high-impact physical activities.
Many women think incontinence is a normal part of aging. Loss of bladder control actually is a major reason for nursing home admission among older women, Fifty percent of incontinent adults do not seek medical attention. In reality, incontinence is not a normal part of aging and never should be regarded as such. Treatment can cure and improve incontinence in the majority of cases.
Types of Incontinence
Commonly encountered incontinence categories are:
* urge incontinence--involuntary loss of urine associated with a strong sensation of urinary urgency;
* stress incontinence--urethral sphincter failure usually associated with increased intraabdominal pressure; and
* mixed-cause incontinence--a combination of urge and stress.
A person also might experience temporary incontinence, called transient or reversible incontinence, overflow incontinence, or reflex (unconscious) incontinence.
Before referring patient for an incontinence management program, I examine the cognitive level of the patient. Severely cognitively impaired patients are not appropriate for incontinence therapy. A baseline voiding record should be established with 24 hours' observation by the nursing staff. Clear communication and coordination with the nursing staff is vital. Usually the duration of a treatment program is seven weeks. I usually start getting measurable outcomes after three weeks. The sample goals I establish are:
* patient will increase time between voiding episode from X hrs to Y hours;
* patient will decrease number of pad changes from X to Y;
* patient will stay dry for X-hour period during daytime, for good hygiene; and
* patient will decrease level of incontinence product used from X to Y (i.e., from diaper to max absorption pad to liner).
In bladder training programs, patients void at scheduled intervals to suppress the micturition reflex, increase bladder capacity and decrease urinary frequency. Two scheduling regimens have been used for long-term care residents: prompted voiding, in which patients are asked if they need to void at regular intervals and then assisted to toilet. The second method is timed voiding, which assigns a voiding schedule at the beginning of treatment. Thereafter, the schedule remains unchanged. A good habit training is imperative.
Neuromuscular Electrical Stimulation
Electrical stimulation of the pelvic floor is used as an adjunct in the conservative treatment of urinary incontinence. Electrical stimulation facilitates urine storage by modifying bladder contractility and detrusor overactivity and by re-educating the pelvic floor muscles. The treatment of this disorder with electrical stimulation is an accepted and reimbursible treatment with associated ICD-9 and CPT treatment coding.
Pelvic muscle exercises
Kegel exercises are best for stress incontinence. Because pelvic floor exercises are safe, effective and free of contraindications and side effects, they should be recommended to all patients with stress incontinence.
Respect for the client's privacy and cultural beliefs is crucial in the treatment process. In a thorough urogenital history, the OT clinician should include any relevant episodes of sexual abuse or trauma to the perineal region.
Therapy is considered successful when voiding occurs at 3- to 4-hour intervals, the patient is continent and sensory symptoms are minimal. Treatment must always be individualized. When you initiate treatment, tell the patient should be told how long it must be continued she can expect improvement. Until that happens, provide enthusiastic support so she doesn't become discouraged.
The patient should understand that treatment selection is often empirical and requires some trial and error. Occupational therapy clinicians should rely on the patient's assessment of the outcome because incontinence is not a life-threatening condition. Some women will consider success to be a reduction in the frequency and severity of incontinence that allows them to resume social and recreational activities. Others will demand continence during even the most vigorous activities.
Occupational therapists can receive training for urinary incontinence treatment at continuing educational courses and seminars. Employing current methods for treatment of urinary incontinence can significantly reduce the billion of dollars this disorder costs annually and, at the same time, improve the quality of life of patients we care for.
Kailash Sahoo, OTR/L, currently works with Sundance Rehabilitation Corporation at Brookside Manor Nursing center, Madill, OK.