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The effect of bladder training on urinary incontinence in community-dwelling older women
The Effect of B odder Troin ng on Urinory ncont nence in Community-Dwe ling Older Women Carol Publicover, RNC, MSN, ARNP, CETN, and M a r y Bear, RN, PhD
rinary incontinence is a major health problem affecting an estimated 13 milU lion Americans, including 15% to 35% of the over 60-year-old population residing in the community.1 Older women are twice as likely to develop this difficulty as are their male counterparts. 2Approximately 60% of the incontinent elderly describe their problem as uncomfortable, embarrassing, and upsetting. 3 The Agency for Health Care Policy and Research r e c o m m e n d s that behavioral interventions be chosen as the first line of treatment for most clients with urinary incontinence. Behavioral m a n a g e m e n t techniques involve analysis of individual s y m p t o m s and voiding habits, followed by application of treatment methods such as habit training, p r o m p t e d voiding, patterned urge response toileting, pelvic muscle exercises, biofeedback, and bladder training (also called bladder retraining). ~,4 Bladder training is a method of behavioral therapy that has been used successfully to reduce the frequency of incontinent episodes in a cognitively intact population. 4-6The concept of bladder training (originally termed bladder drill or bladder discipline) was first described by Jeffcoate and Francis in 1966. 5The primary goal of bladder training is to restore normal bladder function through the use of a patient education program and mandatory voiding schedule. Methods of client education used in bladder training are both visual and verbal. People undergoing bladder training are taught basic anatomy and physiology of the lower urinary tract and concepts of continence as a learned behavior. The individual is then given a description of the program, and the responsibilities of both the client and health care professional are reviewed. A voiding protocol
Objective: The effect of bladder training on urinary incontinence among a group of community-based older women was investigated. Design: Quasi-experimental. Setting ond Subjects: Nineteen functionally independent, community-dwelling women, a g e d 64 to 88 years, with a history of urinary incontinence occurring at least once a week, participated in the study. Methods: Bladder training methods consisted of mandatory voiding schedules, self-monitored voiding records, and weekly telephone communication between subject and researcher, Moin Outcome Measures:The number of incontinent episodes over a 1-week period was used to determine the effectiveness of bladder training. Results: The mean frequency of incontinent episodes at baseline was compared to the frequency of incontinent episodes at both end of treatment and at 6-month follow-up. Conclusions: Bladder training is effective in reducing episodes of urinary incontinence in community-dwelling older women. (J WOCN 1997;24:319-24)
is negotiated and established for each individual. The initial voiding interval reflects an average voiding frequency documented in a patient-maintained diary. Weekly increases in length of span between scheduled urination are determined by the individual's ability to maintain continence and adhere to the established voiding schedule. Self-monitoring is an important aspect of bladder training. 4Patients are expected to keep an accurate weekly voiding record, documenting episodes of both incontinence and scheduled urination. Voiding records demonstrate progress to the individual and serve as the basis for ensuing changes in the voiding schedule. Positive reinforcement and a therapeutic relationship are vital components of the bladder training program. ~Weekly review of each voiding record enables the health care professional to identify any potential problems and provide instruction for the ensuing w e e k ' s voiding protocol. Frequent communication also presents an
Carol Publicover, RNC, MSN,ARNP, CETN,is Nurse Practitioner-Nursing Coordinator of the Wound Manogement Center/Hyperboric Medicine Services ot Florida Hospital, Orlando. Mary Bear, RN, PhD, is an Associofe Professor, Universityof Central Florida, Orlando. Reprint requests: Carol Publicover, RNC, MSN,ARNP, CETN,849 Post Lane, Orlando, FL32804-3037. Copyright @ 1997by the Wound, Ostomy ond Continence Nurses Society. 1071-5754/97/$5.00+ 0
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opportunity to praise the client's efforts and offer continued support for reaching the established goal. In an extensive review of bladder training studies conducted before 1983, Hadley 7 noted that subjects were typically hospitalized during the study, were functionally or cognitively impaired, and were frequently given additional interventions (in the form of exercises or medications) along with their bladder training. More recent studies also have used multiple behavioral methods to evaluate and treat urinary incontinence. Rose and associates s used a combination of Kegel exercises, habit training, biofeedback, and relaxation techniques in their exploratory study of communitydwelling older adults with urinary incontinence. Two groups of predominantly female subjects (a total of 38 subjects) with urinary incontinence were treated after maintaining a voiding record for 2 weeks. At the conclusion of the intervention, subjects in both groups recorded a 77% reduction in episodes of urinary incontinence? In a controlled study, McDowell and colleagues 9studied the effect of biofeedback, pelvic muscle exercise, and other behavioral techniques on urinary incontinence among a group of 29 incontinent community-dwelling elders. They achieved an average of 81.6% reduction in number of incontinent episodes, and 10 of their subjects were free of incontinent episodes after intervention. 9 Fantl and associates 1°conducted a controlled, randomized study in an ambulatory clinic with use of bladder training as an isolated treatment for urinary incontinence. One hundred and thirtyone community-based women aged 55 years and older underwent a pelvic examination and extensive urodynamic assessment, including dynamic urethral profilometry before participation in the program. After treatment, 45 of 60 subjects (75%) assigned to the bladder training program experienced at least a 50% decrease in incontinent episodes, and 12% experienced no incontinent episodes after the intervention. In contrast, 15 of 63 control group subjects reported at least a50% decrease in incontinent episodes, and 3% reported no incontinence. These results were maintained at 6-month follow u p ) ° Despite these encouraging findings, a literature review revealed no further
studies evaluating the effectiveness of bladder training as a solitary intervention for urinary incontinence among community-dwelling women. This study is an extension of the work done by Fantl and colleagues.l° It has been modified from a clinic-based study, with invasive procedures and weekly subject attendance, to one of noninvasive assessment and frequent (at least weekly) subject contact in the form of home visits and telephone interaction. The purpose of this study was to determine whether bladder training would reduce the number of voiding accidents in a population of community-dwelling older women. No attempt was made to modify diet, medications, or exercise patterns. It was hypothesized that episodes of urinary incontinence in community-dwelling older women would be reduced when therapy was administered to subjects in their h o m e s - - w i t h use of noninvasive evaluative techniques and a program of bladder training as the solitary method of treatment.
METHODS
Setting The research was conducted in the central Florida area. Participants came from both urban and rural communities located within a 50-mile radius of Orlando. Both initial and poststudy interviews were conducted in the homes of each individual participant.
Subjects Study participants were recruited from an announcement placed in a newsletter generated by the National Association for Continence (NAFC) and distributed to its central Florida membership. The NAFC newsletter solicited volunteers to participate in a program for older women with urinary control problems. Twenty-one inquiries were received in the mail within a period of 2 months after newsletter distribution. Of this number, 19 women were included in the s t u d y - - t w o could not be contacted by us. Sixteen subjects remained in the study until its conclusion. Reasons given for dropping out of the study before its completion were family illness and the inability to maintain a consistent pattern of scheduled voiding based on social demands.
JWOCN Volume 24, Number 6
Instruments Several instruments were used to determine subject eligibility. The existence of urinary incontinence was validated by use of a brief voiding questionnaire adapted from a tool used by Fantl and associates 1° and suggested by the Agency for Health Care Policy and Research. ~1Participants also documented episodes of urine loss in a 3-day voiding diary. 12Mental competence was evaluated with Pfeifer's Short Portable Mental Status Questionnaire. 13 Independence in toileting was measured by a score of less than 25 on an adaptation of the Performance on Timed Toileting Instrument.I4 Absence of red or white blood cells in the urine was established with a standard reagent strip for urinalysis at baseline only.
Procedure Data were collected between November 1994 and August 1995. All data were collected by author Publicover, a nurse practitioner and certified ET nurse. Each participant was contacted by telephone to arrange an interview in the subject's residence. During this initial in-home interview, subjects were advised of the purpose and goals of the study as well as the criteria necessary for participation. Participants were screened for the presence of urinary incontinence with use of questions recommended by the Agency for Health Care Policy and Research11: (1) Do you have trouble holding your water? (2) Are there times when you cannot reach the toilet on time? and (3) Do you wear padding to contain your urine? Women who reported an involuntary loss of urine occurring on at least a weekly basis, in an amount that they considered sufficient to be a problem, were included in the study. All w o m e n provided informed consent before participation. The protocol for this investigation was reviewed and approved by the Institutional Review Board of the University of Florida. A dipstick urinalysis and a brief physical assessment, typical of the one performed by home health nurses, were completed during baseline assessment. In addition, participants were required to have undergone a comprehensive physical examination (including pelvic evaluation) by their primary health care provider within .the previous year. Subjects were excluded from participation if they had a urinary tract infection, a diagnosis of fecal ira-
Publicover and Bear 321
paction or urinary retention as detected by patient history or noninvasive physical examination, and functional or cognitive skills inadequate to accomplish the self-toileting process. On the initial visit, each participant was given a packet containing a 3-day voiding diary, a set of clock guides, and four weekly voiding records (Figure 1). We demonstrated the method of maintaining a voiding diary for 3 continuous days, teaching the potential subject to note each episode of continent voiding with a "T" (for toilet), and each incident of urinary incontinence with an "A" (for accident) in the appropriate space of the voiding diary. A mutually agreeable date for diary initiation and completion was established. Subjects were given a stamped, addressed envelope in which to mail the completed diary back, and they were advised to save the clock guides and weekly voiding records pending further instruction. Once baseline voiding diary contents were received and analyzed, a copy of individualized bladder training instructions were mailed to each participant (Box 1). Three days later, the participant was contacted by telephone to review all learning materials, and to provide verbal instructions for maintaining the first week's voiding record. Voiding schedules were based on information obtained from the subject's voiding diary. Methods of prompting voiding and ensuring compliance to the voiding schedule were tailored to the needs of individual study participants. A daily clock guide was selected from the established series (each individual guide depicted a different interval of time ranging from 30 minutes to 21~hours). Subjects were encouraged to contact us promptly if they had any questions or difficulties in following the instructions. At the conclusion of week 1, we again telephoned study participants. Positive reinforcement was p r o v i d e d for their efforts during the previous w e e k and they were asked whether they had experienced any difficulty either complying with the established schedule or adhering to the written instructions. Based on data documented in the voiding record, we gave instructions on a voiding interval for the ensuing week. This schedule was based on performance from the previous week. Those subjects who were able to maintain the previous week's schedule, and
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T=TOILET Mon.
Tue.
Box 1. Bladder training instructions
A=ACCIDENT Wed.
Thu.
Fri.
Sat.
Sun.
1. Begin bladder training the morning of
7am
2. Empty your bladder as soon as you get up in the morning and write the time on your voiding record. 3. Throughout the entire day and evening, empty your bladder every and record this with a "T" in the designated column of your voiding record. 4. If you feel a strong urge to urinate before the next scheduled time, try to postpone it to the appropriate moment. Take deep breaths to relax, or distract your thoughts by humming or reading. 5, If it becomes necessary for you to empty your bladder before schedule, return to the established routine by urinating again at the next scheduled time. 6. If you have a voiding accident, place an "A" in the designated column of your voiding record. 7. Repeat this procedure every day for a week whether or not you feel the need to urinate. 8. Do not schedule voiding between bedtime and the time you get up in the morning. Empty your bladder during the night as needed.
8am 9am 10am llam 12n ipm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm llpm 12pm lam 2am 3am 4am 5am 6am Total
Figure 1, Weekly voiding record. who experienced two or less incidents of urinary incontinence, were instructed to increase their voiding span by 30 minutes. In contrast, those who experienced more than two incontinent episodes during the previous week were instructed to make no change in their voiding schedule. Each subject was instructed to post results for the ensuing week on a second voiding record. This p r o c e d u r e was r e p e a t e d weekly until each study participant had completed a total of 4 consecutive weeks of bladder training. All completed voiding records were retained by participants until study completion. After 4 weeks of bladder training were concluded, we made a final visit to each subject. At this time, voiding records were collected, the subject was thanked for
her cooperation and assistance, and the subject's level of satisfaction with the bladder training p r o g r a m was evaluated. Continued compliance with the final voiding regimen was emphasized, and assistance with expanded voiding intervals was offered to those who expressed an interest. Each participant was given a copy of Urinary Incontinence in Adults, A Patient's Guide. 15
Six months after completion of treatment, participants were mailed a questionnaire and 3-day voiding record. Each subject responded to questions regarding both personal satisfaction with study participation and continued compliance with a voiding schedule. Fifteen participants were able to complete the 3-day voiding record and forward it to us by return mail. One w o m a n was not able to do so because of physical limitations.
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V o l u m e 24, N u m b e r 6
RESULTS
Table 1. D e m o g r a p h i c
characteristics
Characteristics
Study Population The participants in this study ranged in age from 64 to 88 years, with a median age of 73.5 years. All of the participants were white and resided independently in the community. Most were unemployed, unmarried, and educated beyond high school (Table 1). All of the participants scored between 8 and 10 (X = 9.58) on Pfeifer's Short Portable Mental Status Questionnaire J 3Independence in toileting was reflected in the mean time of 23.74 seconds required by the sample to accomplish the five m a n d a t o r y tasks on the Performance on Timed Toileting Instrument. TM
Voiding Accidents The effectiveness of bladder training was measured by comparing the prevalence of reported voiding accidents at baseline with both the final 3 days of treatment and a period of 3 consecutive days occurring 6 months later (Table 2). Pairedt tests revealed significant decreases in the number of voiding accidents between the group at baseline and end of treatment (t = 4.40; p = 0.001), and between the mean baseline and 6-month follow-up (t = 4.21;p = 0.001). No significant differences were found when comparing results at end of treatment and at 6-month follow-up (t = -0.90; p > 0.10). The percentage of reduction in number of voiding accidents at the end of intervention is represented in Table 3. The mean reduction in number of incontinent episodes for the entire study group was 87.3%, and 11 of 16 (69%) were completely continent after bladder training. Two subjects experienced a 50% reduction in episodes of urine loss, representing the minimum response to treatment.
DISCUSSION This study demonstrated that urinary continence among a group of communitydwelling older women was improved after a 4-week period of bladder training. Bladder training proved even more effective when the results of this study are compared with those reported in other investigations of this behavioral method?-1° Our results may have been influenced by the characteristics of the group. Specifically, the women who participated in this study
323
f
%
A g e (YO 64-71
6
31.57
72-79
8
42.11
80-88
5
26.32
White
19
100.00
Race Work status Employed Unemployed
4
21.06
15
78.94
9
47,38
10
52.63
Marital status With spouse Without spouse Educational background No high school
1
5.30
A t least s o m e high school
6
31.58
12
63.16
E d u c a t e d b e y o n d high school n=19,
Table 2. N u m b e r o f v o i d i n g a c c i d e n t s Measure
Baseline
End of treatment
6-Month follow-up
X
4.8125
0.9375
1.0000
SD
5,3190
2.0810
2.0000
Range
1-23
0-8
0-7
t
4.40
4,21
p
0.001
0.001
n=16.
Table 3. P e r c e n t a g e
of reduction
% Reduction
Sample number at end of treatment
100 83 78
of voiding accidents
Sample number at 6-month follow-up
11
10
1 1
1 --
75 71
---
1 1
70 65
-1
1 --
56 50
-2
1 --
Unknown
--
1
n=16,
demonstrated independence in toileting, absence of significant cognitive or functional deficits, and otherwise good health. Factors such as the use of individualized teaching methods, home-based interventions, and an unhurried manner
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a d a p t e d by us m a y have affected the outcome of bladder training. The absence of invasive or uncomfortable assessment procedures may have promoted compliance with bladder training by deleting the anxiety and physical discomfort associated with invasive testing procedures. Weekly telephone calls to each study participant also may have contributed to the positive results obtained in this study population. During these calls, reinforcement of teaching was supplemented by statements of understanding, acceptance, reassurance, and positive reinforcement. These supplemental measures were advocated by W y m a n and Fantl 6 based on their experiences with bladder training among community-dwelling women. Two final factors that may have influenced study findings were prior knowledge and motivation. Each study participant belonged to the NAFC, an organization devoted to assisting individuals who experience difficulty with incontinence. Established membership in this group implies a concern with involuntary urine loss and a commitment to its successful resolution.
Limitations The limitations of the current study include the small sample size, the fact that subjects were self-referred, and the lack of a quantitative test to compare changes in urine loss (such as a pad test). In addition, no comparison cohort was included, and the magnitude of supplemental factors, including emotional support and focused concern on the problem of urine loss, cannot be determined.
Recommendations for Future Research This study adds further support to the effectiveness of bladder training as an early intervention for urinary incontinence. Replication of this work in both larger and more ethnically diverse populations is recommended. An additional consideration for future research is the use of bladder training as a preventive measure, incorporating teaching with existent health
education offered during annual health revue. REFERENCES 1. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Rockville (MD): US Department of Health and Human Services; 1996. 2. Herzog A, Fultz N. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990;38:273-81. 3. Ouslander J, Abelson S. Perceptions of urinary incontinence among elderly outpatients. Gerontologist 1990;30:369-72. 4. Coiling J, Newman D, McCormick K, Pearson B. Behavioral management strategies for urinary incontinence. J WOCN 1993;20:9-13. 5. Jeffcoate T, Francis W. Urgency incontinence in the female. Am J Obstet Gyneco11966;94:604-18. 6. Wyman J, Fantl J. Bladder training in ambulatory care management of urinary incontinence. Urol Nurs 1991;13:11-17. 7. Hadley E. Bladder training and related therapies for urinary incontinence in older people. JAMA 1986;256:372-9. 8. Rose M, Baigis-Smith J, Smith D, Newman D. Behavioral management of urinary incontinence in homebound older adults. Home Healthc Nurse 1990;8:10-5. 9. McDowell J, Burgio K, Dombrowski M, Locker J, Rodrigues E. An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients. J A m Geriatr Soc 1992;40:370-4. 10. Fantl J, W y m a n J, McClish D, Harkins S, Elswick R, Taylor J, Hadley E. Efficacy of bladder training in older w o m e n with urinary incontinence. J A M A 1991 ;265:603-I3. 1 I. A g e n c y for Health Care Policy and Research. Urinary incontinence in adults: clinical practice guideline. Rockville (MD): US Department of Health and H u m a n Services; 1992. 12. Lenta G, Stanton S. Urinary diary: designing a shorter diary. Int Urogynecol J 1992;3:69-75. 13. Pfeifer E. A short portable mental status questionnaire forthe assessment of organic brain deficit in the elderly patient. J A m Geriatr Soc 1975;23:433-41. 14. Ouslander J, Morishita L, Blaustein J, Blaustein J, Orzeck S, Dunn S, et al. Clinical,functional, and psychosocial characteristics of an incontinent nursing h o m e population. J Geronto11987;42:63 I7. 15. A g e n c y for Health Care Policy and Research. Urinary incontinence in adults: a patient's guide. Rockville (MD): US Department of Health and H u m a n Services; 1992.
rinary incontinence is a major health problem affecting an estimated 13 milU lion Americans, including 15% to 35% of the over 60-year-old population residing in the community.1 Older women are twice as likely to develop this difficulty as are their male counterparts. 2Approximately 60% of the incontinent elderly describe their problem as uncomfortable, embarrassing, and upsetting. 3 The Agency for Health Care Policy and Research r e c o m m e n d s that behavioral interventions be chosen as the first line of treatment for most clients with urinary incontinence. Behavioral m a n a g e m e n t techniques involve analysis of individual s y m p t o m s and voiding habits, followed by application of treatment methods such as habit training, p r o m p t e d voiding, patterned urge response toileting, pelvic muscle exercises, biofeedback, and bladder training (also called bladder retraining). ~,4 Bladder training is a method of behavioral therapy that has been used successfully to reduce the frequency of incontinent episodes in a cognitively intact population. 4-6The concept of bladder training (originally termed bladder drill or bladder discipline) was first described by Jeffcoate and Francis in 1966. 5The primary goal of bladder training is to restore normal bladder function through the use of a patient education program and mandatory voiding schedule. Methods of client education used in bladder training are both visual and verbal. People undergoing bladder training are taught basic anatomy and physiology of the lower urinary tract and concepts of continence as a learned behavior. The individual is then given a description of the program, and the responsibilities of both the client and health care professional are reviewed. A voiding protocol
Objective: The effect of bladder training on urinary incontinence among a group of community-based older women was investigated. Design: Quasi-experimental. Setting ond Subjects: Nineteen functionally independent, community-dwelling women, a g e d 64 to 88 years, with a history of urinary incontinence occurring at least once a week, participated in the study. Methods: Bladder training methods consisted of mandatory voiding schedules, self-monitored voiding records, and weekly telephone communication between subject and researcher, Moin Outcome Measures:The number of incontinent episodes over a 1-week period was used to determine the effectiveness of bladder training. Results: The mean frequency of incontinent episodes at baseline was compared to the frequency of incontinent episodes at both end of treatment and at 6-month follow-up. Conclusions: Bladder training is effective in reducing episodes of urinary incontinence in community-dwelling older women. (J WOCN 1997;24:319-24)
is negotiated and established for each individual. The initial voiding interval reflects an average voiding frequency documented in a patient-maintained diary. Weekly increases in length of span between scheduled urination are determined by the individual's ability to maintain continence and adhere to the established voiding schedule. Self-monitoring is an important aspect of bladder training. 4Patients are expected to keep an accurate weekly voiding record, documenting episodes of both incontinence and scheduled urination. Voiding records demonstrate progress to the individual and serve as the basis for ensuing changes in the voiding schedule. Positive reinforcement and a therapeutic relationship are vital components of the bladder training program. ~Weekly review of each voiding record enables the health care professional to identify any potential problems and provide instruction for the ensuing w e e k ' s voiding protocol. Frequent communication also presents an
Carol Publicover, RNC, MSN,ARNP, CETN,is Nurse Practitioner-Nursing Coordinator of the Wound Manogement Center/Hyperboric Medicine Services ot Florida Hospital, Orlando. Mary Bear, RN, PhD, is an Associofe Professor, Universityof Central Florida, Orlando. Reprint requests: Carol Publicover, RNC, MSN,ARNP, CETN,849 Post Lane, Orlando, FL32804-3037. Copyright @ 1997by the Wound, Ostomy ond Continence Nurses Society. 1071-5754/97/$5.00+ 0
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opportunity to praise the client's efforts and offer continued support for reaching the established goal. In an extensive review of bladder training studies conducted before 1983, Hadley 7 noted that subjects were typically hospitalized during the study, were functionally or cognitively impaired, and were frequently given additional interventions (in the form of exercises or medications) along with their bladder training. More recent studies also have used multiple behavioral methods to evaluate and treat urinary incontinence. Rose and associates s used a combination of Kegel exercises, habit training, biofeedback, and relaxation techniques in their exploratory study of communitydwelling older adults with urinary incontinence. Two groups of predominantly female subjects (a total of 38 subjects) with urinary incontinence were treated after maintaining a voiding record for 2 weeks. At the conclusion of the intervention, subjects in both groups recorded a 77% reduction in episodes of urinary incontinence? In a controlled study, McDowell and colleagues 9studied the effect of biofeedback, pelvic muscle exercise, and other behavioral techniques on urinary incontinence among a group of 29 incontinent community-dwelling elders. They achieved an average of 81.6% reduction in number of incontinent episodes, and 10 of their subjects were free of incontinent episodes after intervention. 9 Fantl and associates 1°conducted a controlled, randomized study in an ambulatory clinic with use of bladder training as an isolated treatment for urinary incontinence. One hundred and thirtyone community-based women aged 55 years and older underwent a pelvic examination and extensive urodynamic assessment, including dynamic urethral profilometry before participation in the program. After treatment, 45 of 60 subjects (75%) assigned to the bladder training program experienced at least a 50% decrease in incontinent episodes, and 12% experienced no incontinent episodes after the intervention. In contrast, 15 of 63 control group subjects reported at least a50% decrease in incontinent episodes, and 3% reported no incontinence. These results were maintained at 6-month follow u p ) ° Despite these encouraging findings, a literature review revealed no further
studies evaluating the effectiveness of bladder training as a solitary intervention for urinary incontinence among community-dwelling women. This study is an extension of the work done by Fantl and colleagues.l° It has been modified from a clinic-based study, with invasive procedures and weekly subject attendance, to one of noninvasive assessment and frequent (at least weekly) subject contact in the form of home visits and telephone interaction. The purpose of this study was to determine whether bladder training would reduce the number of voiding accidents in a population of community-dwelling older women. No attempt was made to modify diet, medications, or exercise patterns. It was hypothesized that episodes of urinary incontinence in community-dwelling older women would be reduced when therapy was administered to subjects in their h o m e s - - w i t h use of noninvasive evaluative techniques and a program of bladder training as the solitary method of treatment.
METHODS
Setting The research was conducted in the central Florida area. Participants came from both urban and rural communities located within a 50-mile radius of Orlando. Both initial and poststudy interviews were conducted in the homes of each individual participant.
Subjects Study participants were recruited from an announcement placed in a newsletter generated by the National Association for Continence (NAFC) and distributed to its central Florida membership. The NAFC newsletter solicited volunteers to participate in a program for older women with urinary control problems. Twenty-one inquiries were received in the mail within a period of 2 months after newsletter distribution. Of this number, 19 women were included in the s t u d y - - t w o could not be contacted by us. Sixteen subjects remained in the study until its conclusion. Reasons given for dropping out of the study before its completion were family illness and the inability to maintain a consistent pattern of scheduled voiding based on social demands.
JWOCN Volume 24, Number 6
Instruments Several instruments were used to determine subject eligibility. The existence of urinary incontinence was validated by use of a brief voiding questionnaire adapted from a tool used by Fantl and associates 1° and suggested by the Agency for Health Care Policy and Research. ~1Participants also documented episodes of urine loss in a 3-day voiding diary. 12Mental competence was evaluated with Pfeifer's Short Portable Mental Status Questionnaire. 13 Independence in toileting was measured by a score of less than 25 on an adaptation of the Performance on Timed Toileting Instrument.I4 Absence of red or white blood cells in the urine was established with a standard reagent strip for urinalysis at baseline only.
Procedure Data were collected between November 1994 and August 1995. All data were collected by author Publicover, a nurse practitioner and certified ET nurse. Each participant was contacted by telephone to arrange an interview in the subject's residence. During this initial in-home interview, subjects were advised of the purpose and goals of the study as well as the criteria necessary for participation. Participants were screened for the presence of urinary incontinence with use of questions recommended by the Agency for Health Care Policy and Research11: (1) Do you have trouble holding your water? (2) Are there times when you cannot reach the toilet on time? and (3) Do you wear padding to contain your urine? Women who reported an involuntary loss of urine occurring on at least a weekly basis, in an amount that they considered sufficient to be a problem, were included in the study. All w o m e n provided informed consent before participation. The protocol for this investigation was reviewed and approved by the Institutional Review Board of the University of Florida. A dipstick urinalysis and a brief physical assessment, typical of the one performed by home health nurses, were completed during baseline assessment. In addition, participants were required to have undergone a comprehensive physical examination (including pelvic evaluation) by their primary health care provider within .the previous year. Subjects were excluded from participation if they had a urinary tract infection, a diagnosis of fecal ira-
Publicover and Bear 321
paction or urinary retention as detected by patient history or noninvasive physical examination, and functional or cognitive skills inadequate to accomplish the self-toileting process. On the initial visit, each participant was given a packet containing a 3-day voiding diary, a set of clock guides, and four weekly voiding records (Figure 1). We demonstrated the method of maintaining a voiding diary for 3 continuous days, teaching the potential subject to note each episode of continent voiding with a "T" (for toilet), and each incident of urinary incontinence with an "A" (for accident) in the appropriate space of the voiding diary. A mutually agreeable date for diary initiation and completion was established. Subjects were given a stamped, addressed envelope in which to mail the completed diary back, and they were advised to save the clock guides and weekly voiding records pending further instruction. Once baseline voiding diary contents were received and analyzed, a copy of individualized bladder training instructions were mailed to each participant (Box 1). Three days later, the participant was contacted by telephone to review all learning materials, and to provide verbal instructions for maintaining the first week's voiding record. Voiding schedules were based on information obtained from the subject's voiding diary. Methods of prompting voiding and ensuring compliance to the voiding schedule were tailored to the needs of individual study participants. A daily clock guide was selected from the established series (each individual guide depicted a different interval of time ranging from 30 minutes to 21~hours). Subjects were encouraged to contact us promptly if they had any questions or difficulties in following the instructions. At the conclusion of week 1, we again telephoned study participants. Positive reinforcement was p r o v i d e d for their efforts during the previous w e e k and they were asked whether they had experienced any difficulty either complying with the established schedule or adhering to the written instructions. Based on data documented in the voiding record, we gave instructions on a voiding interval for the ensuing week. This schedule was based on performance from the previous week. Those subjects who were able to maintain the previous week's schedule, and
JWOCN 322
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November 1997
T=TOILET Mon.
Tue.
Box 1. Bladder training instructions
A=ACCIDENT Wed.
Thu.
Fri.
Sat.
Sun.
1. Begin bladder training the morning of
7am
2. Empty your bladder as soon as you get up in the morning and write the time on your voiding record. 3. Throughout the entire day and evening, empty your bladder every and record this with a "T" in the designated column of your voiding record. 4. If you feel a strong urge to urinate before the next scheduled time, try to postpone it to the appropriate moment. Take deep breaths to relax, or distract your thoughts by humming or reading. 5, If it becomes necessary for you to empty your bladder before schedule, return to the established routine by urinating again at the next scheduled time. 6. If you have a voiding accident, place an "A" in the designated column of your voiding record. 7. Repeat this procedure every day for a week whether or not you feel the need to urinate. 8. Do not schedule voiding between bedtime and the time you get up in the morning. Empty your bladder during the night as needed.
8am 9am 10am llam 12n ipm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm llpm 12pm lam 2am 3am 4am 5am 6am Total
Figure 1, Weekly voiding record. who experienced two or less incidents of urinary incontinence, were instructed to increase their voiding span by 30 minutes. In contrast, those who experienced more than two incontinent episodes during the previous week were instructed to make no change in their voiding schedule. Each subject was instructed to post results for the ensuing week on a second voiding record. This p r o c e d u r e was r e p e a t e d weekly until each study participant had completed a total of 4 consecutive weeks of bladder training. All completed voiding records were retained by participants until study completion. After 4 weeks of bladder training were concluded, we made a final visit to each subject. At this time, voiding records were collected, the subject was thanked for
her cooperation and assistance, and the subject's level of satisfaction with the bladder training p r o g r a m was evaluated. Continued compliance with the final voiding regimen was emphasized, and assistance with expanded voiding intervals was offered to those who expressed an interest. Each participant was given a copy of Urinary Incontinence in Adults, A Patient's Guide. 15
Six months after completion of treatment, participants were mailed a questionnaire and 3-day voiding record. Each subject responded to questions regarding both personal satisfaction with study participation and continued compliance with a voiding schedule. Fifteen participants were able to complete the 3-day voiding record and forward it to us by return mail. One w o m a n was not able to do so because of physical limitations.
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V o l u m e 24, N u m b e r 6
RESULTS
Table 1. D e m o g r a p h i c
characteristics
Characteristics
Study Population The participants in this study ranged in age from 64 to 88 years, with a median age of 73.5 years. All of the participants were white and resided independently in the community. Most were unemployed, unmarried, and educated beyond high school (Table 1). All of the participants scored between 8 and 10 (X = 9.58) on Pfeifer's Short Portable Mental Status Questionnaire J 3Independence in toileting was reflected in the mean time of 23.74 seconds required by the sample to accomplish the five m a n d a t o r y tasks on the Performance on Timed Toileting Instrument. TM
Voiding Accidents The effectiveness of bladder training was measured by comparing the prevalence of reported voiding accidents at baseline with both the final 3 days of treatment and a period of 3 consecutive days occurring 6 months later (Table 2). Pairedt tests revealed significant decreases in the number of voiding accidents between the group at baseline and end of treatment (t = 4.40; p = 0.001), and between the mean baseline and 6-month follow-up (t = 4.21;p = 0.001). No significant differences were found when comparing results at end of treatment and at 6-month follow-up (t = -0.90; p > 0.10). The percentage of reduction in number of voiding accidents at the end of intervention is represented in Table 3. The mean reduction in number of incontinent episodes for the entire study group was 87.3%, and 11 of 16 (69%) were completely continent after bladder training. Two subjects experienced a 50% reduction in episodes of urine loss, representing the minimum response to treatment.
DISCUSSION This study demonstrated that urinary continence among a group of communitydwelling older women was improved after a 4-week period of bladder training. Bladder training proved even more effective when the results of this study are compared with those reported in other investigations of this behavioral method?-1° Our results may have been influenced by the characteristics of the group. Specifically, the women who participated in this study
323
f
%
A g e (YO 64-71
6
31.57
72-79
8
42.11
80-88
5
26.32
White
19
100.00
Race Work status Employed Unemployed
4
21.06
15
78.94
9
47,38
10
52.63
Marital status With spouse Without spouse Educational background No high school
1
5.30
A t least s o m e high school
6
31.58
12
63.16
E d u c a t e d b e y o n d high school n=19,
Table 2. N u m b e r o f v o i d i n g a c c i d e n t s Measure
Baseline
End of treatment
6-Month follow-up
X
4.8125
0.9375
1.0000
SD
5,3190
2.0810
2.0000
Range
1-23
0-8
0-7
t
4.40
4,21
p
0.001
0.001
n=16.
Table 3. P e r c e n t a g e
of reduction
% Reduction
Sample number at end of treatment
100 83 78
of voiding accidents
Sample number at 6-month follow-up
11
10
1 1
1 --
75 71
---
1 1
70 65
-1
1 --
56 50
-2
1 --
Unknown
--
1
n=16,
demonstrated independence in toileting, absence of significant cognitive or functional deficits, and otherwise good health. Factors such as the use of individualized teaching methods, home-based interventions, and an unhurried manner
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N o v e m b e r 1997
a d a p t e d by us m a y have affected the outcome of bladder training. The absence of invasive or uncomfortable assessment procedures may have promoted compliance with bladder training by deleting the anxiety and physical discomfort associated with invasive testing procedures. Weekly telephone calls to each study participant also may have contributed to the positive results obtained in this study population. During these calls, reinforcement of teaching was supplemented by statements of understanding, acceptance, reassurance, and positive reinforcement. These supplemental measures were advocated by W y m a n and Fantl 6 based on their experiences with bladder training among community-dwelling women. Two final factors that may have influenced study findings were prior knowledge and motivation. Each study participant belonged to the NAFC, an organization devoted to assisting individuals who experience difficulty with incontinence. Established membership in this group implies a concern with involuntary urine loss and a commitment to its successful resolution.
Limitations The limitations of the current study include the small sample size, the fact that subjects were self-referred, and the lack of a quantitative test to compare changes in urine loss (such as a pad test). In addition, no comparison cohort was included, and the magnitude of supplemental factors, including emotional support and focused concern on the problem of urine loss, cannot be determined.
Recommendations for Future Research This study adds further support to the effectiveness of bladder training as an early intervention for urinary incontinence. Replication of this work in both larger and more ethnically diverse populations is recommended. An additional consideration for future research is the use of bladder training as a preventive measure, incorporating teaching with existent health
education offered during annual health revue. REFERENCES 1. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Rockville (MD): US Department of Health and Human Services; 1996. 2. Herzog A, Fultz N. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990;38:273-81. 3. Ouslander J, Abelson S. Perceptions of urinary incontinence among elderly outpatients. Gerontologist 1990;30:369-72. 4. Coiling J, Newman D, McCormick K, Pearson B. Behavioral management strategies for urinary incontinence. J WOCN 1993;20:9-13. 5. Jeffcoate T, Francis W. Urgency incontinence in the female. Am J Obstet Gyneco11966;94:604-18. 6. Wyman J, Fantl J. Bladder training in ambulatory care management of urinary incontinence. Urol Nurs 1991;13:11-17. 7. Hadley E. Bladder training and related therapies for urinary incontinence in older people. JAMA 1986;256:372-9. 8. Rose M, Baigis-Smith J, Smith D, Newman D. Behavioral management of urinary incontinence in homebound older adults. Home Healthc Nurse 1990;8:10-5. 9. McDowell J, Burgio K, Dombrowski M, Locker J, Rodrigues E. An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients. J A m Geriatr Soc 1992;40:370-4. 10. Fantl J, W y m a n J, McClish D, Harkins S, Elswick R, Taylor J, Hadley E. Efficacy of bladder training in older w o m e n with urinary incontinence. J A M A 1991 ;265:603-I3. 1 I. A g e n c y for Health Care Policy and Research. Urinary incontinence in adults: clinical practice guideline. Rockville (MD): US Department of Health and H u m a n Services; 1992. 12. Lenta G, Stanton S. Urinary diary: designing a shorter diary. Int Urogynecol J 1992;3:69-75. 13. Pfeifer E. A short portable mental status questionnaire forthe assessment of organic brain deficit in the elderly patient. J A m Geriatr Soc 1975;23:433-41. 14. Ouslander J, Morishita L, Blaustein J, Blaustein J, Orzeck S, Dunn S, et al. Clinical,functional, and psychosocial characteristics of an incontinent nursing h o m e population. J Geronto11987;42:63 I7. 15. A g e n c y for Health Care Policy and Research. Urinary incontinence in adults: a patient's guide. Rockville (MD): US Department of Health and H u m a n Services; 1992.