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Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults
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Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults Javier Jerez-Roig a,b,*, Dyego L.B. Souza c, Fabienne L.J.S. Amaral a, Kenio C. Lima a a Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil b Servicio de Rehabilitacio´n, Hospital Can Misses, Calle Corona s/n, 07800 Ibiza, Illes Baleares, Spain c Department of Collective Health, Federal University of Rio Grande do Norte, Campus Universita´rio s/n, CEP: 59078-970, Lagoa Nova, Natal-RN, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 May 2014 Received in revised form 4 February 2015 Accepted 6 February 2015 Available online xxx
The objective of this work is to determine the prevalence of FI and associated factors in institutionalized elderly. A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes (NHs) of the city of Natal (Northeast Brazil). Individuals over the age of 60 were included in the study, while those hospitalized or in terminal phase were excluded. Data collection included sociodemographic information, FI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity and Pfeiffer test for cognitive status). FI was verified through the Minimum Data Set (MDS) 3.0, which was also used to assess toileting programs. The Chi-square test and the linear Chisquare test were performed for bivariate analysis, as well as logistic regression for multivariate analysis. The final sample consisted of 321 elderly, mostly females, with mean age of 81.5 years. The prevalence of FI was 42.68% (CI 95%, 37.39–48.15). Most residents presenting FI were always incontinent (83.9%) and the most frequent incontinence type was total FI (solid and liquid stools). Incontinence control measures were applied only to 9.7% of the residents. The final model revealed a statistically significant association between FI and functional and cognitive impairments. It is concluded that FI is a health issue that affects almost half of the institutionalized elderly, and is associated with functional and cognitive disability. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aging Elderly NHs FI
1. Introduction Fecal incontinence (FI) is a common gastrointestinal complaint in elderly individuals, defined as the involuntary loss of stool or inability to control stool from expulsion, which is a social and hygienic problem (Norton, Whitehead, Bliss, Harari, & Lang, 2010; Shah, Chokhavatia, & Rose, 2012). Although it is a health issue frequently neglected, it affects between 2% and 20% of the elderly in community settings and prevalence increases considerably when an institution environment is considered (Aslan, Beji, Erkan, Yalcin, & Gungor, 2009; Leung & Rao, 2009; Leung & Schnelle, 2008; Saga, Vinsnes, Morkved, Norton, & Seim, 2013; Shah et al., 2012; Zarate, Lopez-Kostner, Vergara, Badilla, & Viviani, 2008). This problem entails a strong impact for health systems, as well as
* Corresponding author at: Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil. Tel.: +55 84 3215 4133; fax: +55 84 3215 4133. E-mail address: [email protected] (J. Jerez-Roig).
social impact to caregivers, family members, and on the health and life quality of the elderly (Leung & Rao, 2009; Shah et al., 2012). In Brazil, it is estimated that FI in the general population varies between 2% and 7%, however this figure may represent an underestimation of cases, due to the fact that the presence/ absence of the issue is auto-reported (Amaro et al., 2009; Santos & Santos, 2011; Santos et al., 2014). Controversy regarding the associated factors still remains for FI, and the subject has been the focus of limited research, especially in institutionalized elderly of Latin America (Santos et al., 2014; Townsend, Matthews, Whitehead, & Grodstein, 2013; Zarate et al., 2008). It is worth noting that continence control measures are not systematically applied in Brazil as in other developed countries such as USA, which could influence FI prevalence (Jerez-Roig, Souza, & Lima, 2013). Therefore the findings of this study contribute to the knowledge base on this specific health issue, frequent in older age groups and consequently, contribute to support prevention and control actions in a NH context. Thus, the objective of this study is to verify the prevalence of FI and associated factors in institutionalized elderly.
http://dx.doi.org/10.1016/j.archger.2015.02.003 0167-4943/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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2. Materials and methods 2.1. Subjects A cross-sectional study is presented herein, with data collection accomplished between the months of October and December 2013, in 10 of the 14 NH certified by the Sanitary Vigilance of the municipality of Natal (Northeast Brazil). The remaining 4 NH declined participation in the study. All elderly individuals were included in the study, i.e., over the age of 60, according to criteria from the World Health Organization (WHO) for developing countries. Exclusion criteria were: hospitalized or palliative care residents (terminal phase). The research team was constituted by the main researcher and by students from the undergraduate Physiotherapy course of the Federal University of Rio Grande do Norte (UFRN). The team met previously in two occasions, to ensure adequate comprehension of the questionnaires and calibration of examiners. A pilot study was carried out with 24 elderly from the first NH studied. The current study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte, approval no. 308/2012. 2.2. Measures The dependent variable of the study was the presence of FI, defined as ‘the involuntary loss of liquid or solid stool’, as accepted by the International Consultation on Incontinence (Norton et al., 2010). This information was extracted from item H4 of MDS version 3.0, which considers fecal continence during the previous 5 days, according to the direct caregiver. The following categories are possible: always continent, occasionally incontinent (1 episode of bowel incontinence), frequently incontinent (2 or more episodes), always incontinent (no episodes of continent bowel movements) and not rated (ostomy or no bowel movements for the entire 5 days). Residents with FI were selected when classified as occasionally, frequently or always incontinent for bowel movements. The MDS is a complete database for standardized assessment in NH, which has also presented high levels of reliability regarding continence status and toileting programs (Saliba & Buchanan, 2012). This tool was also used to assess urinary incontinence, devices (including ostomy), constipation and if bowel toileting programs were applied. Ostomy cases were accounted for, but were excluded from bivariate analysis. The direct caregiver also answered questions regarding the use of diapers and daily amount, classification of FI according to the type of feces (solid, liquid, or both) (Johanson, Irizarry, & Doughty, 1997), as well as the daily mean of bowel movements, presence of diarrhea and use of laxatives. A period of 5 days was considered to assess all variables regarding incontinence and bowel patterns (Saliba & Buchanan, 2012). Sociodemograhic variables were also collected (age, gender, race, education level, marital status, number of children and births, reason for institutionalization, residency time, free time occupation/hobbies, retirement, finance administration, health plan and ratio number of elderly per caregiver) as well as variables related to the NH (type of NH, length of stay and ratio residents/caregiver), and related to health conditions (presence and number of comorbidities, diabetes, cancer, prostate cancer, Parkinson’s disease, Alzeimer’s disease, stroke, arterial hypertension, kidney insufficiency, cardiovascular disease, pulmonary disease, osteoporosis, rheumatic disease, mental disease, vaginal, anal–rectal and prostate surgery records, consumption of alcohol, current and past consumption of tobacco, urinary infection within the last 30 days, hip fracture within the last 60 days, daily medication and number of medicines). All these variables were collected from medical records and complemented by information given by the main caregiver and healthcare professionals.
The mobility status was also considered (walks without aid, walks with aid, wheelchair user and bedridden) along with the functional capacity for activities of daily living (ADL), through the validated Portuguese version of the Barthel Index (Cincura et al., 2009), excluding the areas corresponding to continence, as described previously (Prado-Villanueva, Bischoffberger-Valde´s, Valderrama-Gama, Verdejo-Bravo, & Damia´n, 2011). Cognitive capacity was evaluated through Pfeiffer’s test, except for those with severe hearing deficit or those who did not speak the language (Martinez-Iglesia et al., 2001). 2.3. Analyses Bivariate analysis was carried out through the Chi-square test (or Fisher’s test) and the linear Chi-square test. The magnitude of association was verified through the prevalence ratio, to a significance level of 95%. Variables with p values lower than 0.20 were analyzed by logistic regression to build the multivariate model, through the Stepwise Forward method. Permanence of the variable in the multiple analysis depended on the Likelihood Ratio Test, absence of collinearity, as well as its capacity to improve the model through the Hosmer and Lemeshow test. Following Miettinen, odds ratio was transformed into prevalence ratio (Miettinen & Cook, 1981). 3. Results Of the total number of elderly, 8 (2.4%) of the individuals were excluded from the study: 6 (1.8%) were hospitalized, 1 (0.3%) was in terminal phase, and 1 (0.3%) was under the age of 60. A total of 321 elderly were included in the study (100% response rate), mostly of the female gender (75.4%) and the mean age was 81.50 (SD: 9.0). Of the total, 49.2% did not have children, 47.4% were single and 25.2% were widows/ers. The majority (63.3%) resided in not-forprofit organizations, and was institutionalized because of the lack of caregivers (46.7%) or because lived alone (13.4%). A total of 268 (83.5%) individuals were long-term stay residents (more than 1 year) and 16.5% were new admissions (up to one year). The mean residency time was 63.2 months (SD: 62.0) and the mean ratio elderly/caregiver was 8.09 (SD: 5.2). The majority of the elderly was retired (95.3%), however did not have private health plans (62.6%). The use of diapers comprehended 66.0% of the elderly and bowel toileting programs were applied to 31 residents (9.7%), through prompted voiding or facilitation of defecation by the use of laxatives. Of the total number of elderly, 40 presented constipation (12.5%), 9 presented diarrhea (2.8%), and 31 used laxatives (11.5%). The daily mean of bowel movements was 1.2 (SD: 0.8). FI prevalence was 42.68% (CI 95%, 37.39–48.15), and there was 1 (0.3%) unclassified case (colostomy). Among the 137 elderly with FI, double (fecal and urinary) incontinence was observed in 135
Table 1 Characteristics of the residents presenting FI (n = 137).
Frequency Occasionally incontinent Frequently incontinent Always incontinent FI type Solid stool Liquid stool Total Bowel toileting program No Yes
n
%
7 15 115
5.1 10.9 83.9
42 14 81
30.7 10.2 59.1
129 8
94.2 5.8
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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Table 2 contains the variables that presented p value equal or lower than 0.20 in the bivariate analysis and were not included in the final model. Multiple analysis showed that FI was associated with functional and cognitive incapacities, assessed by the Pfeiffer scale, adjusted by the variables age, race, stroke, and reason for institutionalization ‘‘lack of caregiver’’ (Table 3). This re-categorization of the variables functional and cognitive incapacities occurred due to a low frequency of FI cases presenting functional independency and intact cognitive capacity. The Hosmer–Lemeshow value was 0.930.
(42.1%) individuals, and only 2 (0.6%) did not present urinary incontinence. The majority of the elderly with FI presented the total type (solid and liquid stool), was always incontinent (not presenting any episode of continence), and did not follow any continence control program. The characteristics of the elderly presenting FI are shown in Table 1. It is worthwhile to mention that in the FI group there were no cases of functional independency, and only one case of slight dependence. For this reason, it was decided to group the categories independency, slight and moderate dependency.
Table 2 Bivariate analysis of the FI associations with independent variables. FI No
Yes
Gender Male Female Marital status Married Other Arterial hypertension Yes No Education level Illiterate-Primary Education I Primary Education II-Superior Daily frequency of bowel movements <2 2 Reason for institutionalization: lived alone No Yes Reason for institutionalization: own choice Yes No Physical activity Yes No Occupation Yes No Consumption of alcohol No Yes Consumption of tobacco No Yes Alzheimer’s disease No Yes Rheumatic disease No Yes Mental disease No Yes Urinary incontinence No Yes Use of laxants No Yes Mobility Walks without aid Walks with aid Wheelchair Bedridden a b c *
n
%
n
33 104
41.8 43.2
46 137
58.2 56.8
0.830a
1 1.03 (0.77–1.39)
22 110
55.0 41.0
18 158
45.0 59.0
0.096a
1 0.75 (0.54–1.02)
45 92
32.6 50.5
93 90
67.4 49.5
0.001a,*
1 0.64 (0.49–0.85)
56 54
37.1 46.2
95 63
62.9 53.8
0.134a
1 1.24 (0.93–1.66)
92 42
40.7 59.2
134 29
59.3 40.8
0.006a,*
1 1.45 (1.13–1.86)
117 12
44.0 27.9
149 31
56.0 72.1
0.047a,*
1 0.63 (0.38–1.04)
0 129
0 43.0
9 171
100.0 57.0
0.037b,*
1 1.75 (1.59–1.94)
7 130
11.9 49.8
52 131
88.1 50.2
<0.001a,*
1 4.20 (2.07–8.50)
28 108
24.8 52.4
85 98
75.2 47.6
<0.001a,*
1 2.12 (1.50–2.99)
136 1
44.0 10.0
173 9
56.0 90.0
0.048b,*
1 0.28 (0.03–1.46)
133 4
45.2 16.0
161 21
54.8 84.0
0.005a,*
1 0.35 (0.14–0.88)
90 47
36.7 62.7
155 28
63.3 37.3
<0.001a,*
1 1.71 (1.34–2.17)
135 2
44.4 12.5
169 14
55.6 87.5
0.012a,*
1 0.28 (0.78–1.03)
115 22
46.0 31.4
135 48
54.0 68.6
0.029*
1 0.68 (0.47–0.99)
2 133
1.6 70.7
127 55
98.4 29.3
<0.001a,*
114 22
40.7 59.5
166 15
59.3 40.5
0.030a,*
11 24 46 56
8.7 37.5 70.8 87.5
116 40 19 8
91.3 62.5 29.2 12.5
<0.001c,*
%
p
PR (CI 95%)
1 45.63 (11.50–181.05) 1 1.46 (1.08–1.97) 1 4.33 (2.27–8.27) 8.17 (4.54–14.68) 10.10 (5.70–17.90)
Chi-square test. Fisher test. Linear trend Chi-square test. Statistically significant.
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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Table 3 Bivariate (Chi-square test) and multiple analysis of the FI associations with independent variables included in the final model. FI No
Yes n Age 50 60–80 81 87 Race Other 57 White 80 Reason for institutionalization: lack of caregiver 52 No Yes 77 Stroke No 100 Yes 37 Functional capacity 21 Independence, low dependence and moderate dependence 116 High dependence Cognitive capacity (Pfeiffer) Intact/Slight and moderate decline 18 Severe decline 116 *
%
n
%
p
PR (CI 95%)
p
Adjusted PR (CI 95%)
35.7 48.3
90 93
64.3 51.7
0.024*
1 1.35 (1.03–1.77)
0.569
1 1.13 (0.74–1.71)
38.3 46.8
92 91
61.7 53.2
0.124
1 1.22 (0.94–1.58)
0.088
1 1.37 (0.95–1.97)
32.5 51.7
108 72
67.5 48.3
0.001*
1 1.59 (1.21–2.09)
0.251
1 1.27 (0.84–1.92)
37.3 71.2
168 15
62.7 28.8
<0.001*
1 1.91 (1.51–2.41)
0.674
1 1.12 (0.65–1.93)
12.4
149
87.6
<0.001*
1
77.3
34
22.7
15.8 61.4
96 73
84.2 38.6
<0.001*
6.26 (4.16–9.43) <0.001*
1 3.89 (2.51–6.03)
1 5.82 (3.78–8.95)
<0.001*
1 3.16 (1.91–5.20)
Statistically significant
4. Discussion From the results of this research, it was observed that almost 43% of the institutionalized elderly presented involuntary losses of feces, a prevalence value that agrees with the ranges presented in literature, which generally vary between 33% and 65% (Saga et al., 2013; Shah et al., 2012; Zarate et al., 2008). However, the severity of the incontinence in this sample was higher, considering that most residents with FI did not present any episodes of continence, with liquid and solid stool losses (Aslan et al., 2009). Therefore, there are few ‘‘light’’ forms of FI, which suggests that institutionalized elderly decline rapidly until losing complete control of sphincters. Despite the high prevalence values, incontinence control measures are applied to a minority of residents, mostly in private NH. This proportion is lower than that reported by other studies and corroborates the fact that only a minority of institutionalized elderly in Brazil are exposed to specific continence therapies (Jerez-Roig et al., 2013; Prado-Villanueva et al., 2011; Roe et al., 2011). Although the objective of this study was not to evaluate the effectiveness of the interventions applied to institutionalized elderly, it must be highlighted that some studies demonstrate the effectiveness of toileting programs in the improvement of constipation and incontinence (Leung & Rao, 2009; Schnelle et al., 2010, 2009). Although FI frequency was higher in older individuals and slightly superior in women, this association did not present significance in the final model, when adjusted by other variables. While several studies carried out in community settings show the association of FI with age and the female gender, the findings of this study reveal that health conditions seem to be more relevant than sociodemographic characteristics in NH settings (Ditah et al., 2014; Melville, Fan, Newton, & Fenner, 2005; Shamliyan et al., 2009; Whitehead et al., 2009). No association was verified between the variables related to NH, such as the length of stay, and FI, which could be due to the fact that elderly in Brazil are not commonly institutionalized for a short recovery period of time with the objective of returning to the community, and frequently the elderly are already admitted in a general poor health state (Jerez-Roig, Santos, Amaral, & Lima, 2015).
The results of the multivariate analysis showed the relationship of FI with severe dependency for ADL and severe cognitive impairment, when adjusted by age, race, stroke and reason for institutionalization ‘‘lack of caregiver’’. Both geriatric syndromes are widely studied in literature and are placed among the most important factors associated with FI, in institutionalized elderly as well as those living in community settings (AlAmeel, Andrew, & MacKnight, 2010; Aslan et al., 2009; Burge, von Gunten, & Berchtold, 2013; Melville et al., 2005; Saga et al., 2013; Shamliyan et al., 2009; Townsend et al., 2013). The prevalence of functional impairment was high in this study: almost 80% of the residents presented some type of functional dependency for ADL, and half of these cases presented total dependency. Functional incapacity is considered to be an important predictor of institutionalization, even stronger than FI, which indicates that a considerable proportion of the elderly is already admitted with an important deterioration of ADL (AlAmeel et al., 2010). Presence of FI is considered a marker of poor health status and can indicate an advanced process of health deterioration (AlAmeel et al., 2010). Longitudinal studies show that incontinence is one of the contributing factors to the decline of functionality for ADL, during the period of residence of the elderly (Burge et al., 2013; Wang, Kane, Eberly, Virnig, & Chang, 2009). Specifically, tasks such as locomotion and use of bathroom are strongly correlated to FI (Saga et al., 2013). In this way, the resident can develop functional incontinence, due to the incapacity to reach the bathroom in a timely fashion, due to mobility problems or due to cognitive decline (Aslan et al., 2009; Saga et al., 2013; Townsend et al., 2013). The relationship between functional incapacity and FI can also be explained by the multifactorial etiology theory of geriatric syndromes, which regards loss of compensatory ability when multiple physical and psychocognitive domains are affected (CollPlanas, Denkinger, & Nikolaus, 2008). Besides, functionality is related to deficits in muscle strength and physical inactivity, which accompany the natural aging process, and can limit significantly the autonomy of the elderly. In this sample, the prevalence of sedentarism was elevated, which is a fact that can contribute to mobility constraints and loss of sphincter control (Coll-Planas et al., 2008; Townsend et al., 2013). In this study,
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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physical inactivity and immobility lost statistical significance when adjusted in the multivariate model. Regarding chronic diseases, it has already been reported that the increase in FI prevalence in the elderly is not explained by the higher presence of comorbidities (Shah et al., 2012). In this study, there were no associations between chronic diseases and FI, and only stroke was present in the multivariate model, as an adjustment variable. Neurological diseases, such as stroke or Alzeimer’s, are broadly cited in literature as variables that can be directly associated with cognitive incapacity, which in turn resulted to be an important factor associated with FI (Aslan et al., 2009; Santos et al., 2014). Cognitive incapacity is a geriatric syndrome highly prevalent in institutionalized elderly: more than 90% of the participants of this study presented some form of cognitive decline and more than 60% presented severe decline. The association between dementia and FI has been identified as one of the most strongly associated with incontinence in the elderly, as it can affect the capacity of reaching the bathroom rapidly. Besides, cognitive decline is considered a predictor of functional incapacity and mobility, which, in turn, can contribute to the development of incontinence (Hatta, Iwahara, Ito, Hatta, & Hamajima, 2011; Leung & Rao, 2009; Offermans, Dumoulin, Hamers, Dassen, & Halfens, 2009). In this study, the majority (98.5%) of the FI residents presented dual incontinence (both urinary and fecal involuntary losses) and, therefore, the association between both types of incontinence was significant in the bivariate analysis. Although this association has already been reported by several authors, the low frequency of cases prevented the permanence of the variable in the multivariate model (Amaro et al., 2009; Aslan et al., 2009; Ditah et al., 2014; Townsend et al., 2013). Medical history of births and surgeries in the pelvic area did not present significant association with FI, as found in studies carried out within the community (rather than in NH environments) (Amaro et al., 2009; Santos et al., 2014). Still, it must be recognized that, as a limitation of the study, some comorbidities could have suffered under-registry, due to the lack of information contained in medical records and low number of diagnosis established in the residents. Furthermore, the Pfeiffer test is currently not validated to the Portuguese language and a validated translation to the Spanish language was employed. The choice was justified by the fact that other instruments, such as the Mini-Mental State Examination, are more exigent for institutionalized elderly populations and require longer applications times, which prevents epidemiological research to be carried out. It must be mentioned that the cross-sectional design of this study does not allow for the establishment of a cause-effect relationship between the variables and, therefore, some of the findings must be interpreted with caution. The present study is remarkable due to the high number of analysis variables and also due to the high representativity of the sample, obtained through participation of the majority of NH in Natal (Northeast Brazil) and through reduced losses, lower than 6% for all analysis variables. After systematic reviews and to the best of the author’s knowledge, this is the largest research carried out in Latin America on FI in NH environments.
5. Conclusions It can be concluded that FI is a health issue that is prevalent in the NH environment, affecting almost half of the institutionalized elderly. Despite the high prevalence and high severity of the issue, incontinence control measures are applied with low frequency and almost exclusively in private NH. Prevalence of FI was similar as found in other countries, but the severity of the continence verified herein was higher.
5
Functional and cognitive incapacity were highly associated with FI, showing the strong association between these two geriatric syndromes and loss of continence. Since these are modifiable and preventable health issues, this finding suggests that these factors must be taken into consideration when planning continence control programs for institutionalized elderly. Due to the fact that fecal continence is one of the last affected capacities in individuals undergoing health decline processes, the loss of continence can be considered an alarm signal that should be avoided or prevented at all costs, aiming at delaying, as much as possible, functional dependency and improving life quality of the elderly. Conflict of interest None declared. Source of funding None declared. References AlAmeel, T., Andrew, M. K., & MacKnight, C. (2010). The association of fecal incontinence with institutionalization and mortality in older adults. American Journal of Gastroenterology, 105, 1830–1834. Amaro, J. L., Macharelli, C. A., Yamamoto, H., Kawano, P. R., Padovani, C. V., & Agostinho, A. D. (2009). Prevalence and risk factors for urinary and fecal incontinence in Brazilian women. International Brazilian Journal of Urology, 35, 592–598. Aslan, E., Beji, N. K., Erkan, H. A., Yalcin, O., & Gungor, F. (2009). The prevalence of and the related factors for urinary and fecal incontinence among older residing in nursing homes. Journal of Clinical Nursing, 18, 3290–3298. Burge, E., von Gunten, A., & Berchtold, A. (2013). Factors favoring a degradation or an improvement in activities of daily living (ADL) performance among nursing home (NH) residents: A survival analysis. Archives of Gerontology and Geriatrics, 56, 250–257. Cincura, C., Pontes-Neto, O. M., Neville, I. S., Mendes, H. F., Menezes, D. F., Mariano, D. C., et al. (2009). Validation of the national institutes of health stroke scale, modified rankin scale and Barthel Index in Brazil: The role of cultural adaptation and structured interviewing. Cerebrovascular Diseases, 27, 119–122. Coll-Planas, L., Denkinger, M. D., & Nikolaus, T. (2008). Relationship of urinary incontinence and late-life disability: Implications for clinical work and research in geriatrics. Zeitschrift fur Gerontologie und Geriatrie, 41, 283–290. Ditah, I., Devaki, P., Luma, H. N., Ditah, C., Njei, B., Jaiyeoba, C., et al. (2014). Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005–2010. Clinical Gastroenterology and Hepatology, 12, 636–643. Hatta, T., Iwahara, A., Ito, E., Hatta, T., & Hamajima, N. (2011). The relation between cognitive function and UI in healthy, community-dwelling, middle-aged and elderly people. Archives of Gerontology and Geriatrics, 53, 220–224. Jerez-Roig, J., Santos, M. M., Amaral, F. L. J. S., & Lima, K. C. (2015). Prevalence of urinary incontinence and associated factors in nursing home residents. Neurourology and Urodynamics (in press) (http://onlinelibrary.wiley.com/doi/10.1002/nau.22675/ abstract). Jerez-Roig, J., Souza, D. L., & Lima, K. C. (2013). Incontineˆncia urina´ria em idosos institucionalizados no brasil: Uma revisa˜o integrativa. Revista Brasileira de Geriatria e Gerontologia, 16, 865–879. Johanson, J. F., Irizarry, F., & Doughty, A. (1997). Risk factors for fecal incontinence in a nursing home population. Journal of Clinical Gastroenterology, 24, 156–160. Leung, F. W., & Rao, S. S. (2009). Fecal incontinence in the elderly. Gastroenterology Clinics of North America, 38, 503–511. Leung, F. W., & Schnelle, J. F. (2008). Urinary and fecal incontinence in nursing home residents. Gastroenterology Clinics of North America, 37, 697–707. Martinez-Iglesia, J., Duenas-Herrero, R., Onis-Vilches, M. C., Aguado-Taberne, C., AlbertColomer, C., & Luque Luque, R. (2001). Spanish language adaptation and validation of the Pfeiffer’s questionnaire (SPMSQ) to detect cognitive deterioration in people over 65 years of age. Medicina Clinica, 117, 129–134. Melville, J. L., Fan, M. Y., Newton, K., & Fenner, D. (2005). Fecal incontinence in US women: A population-based study. American Journal of Obstetrics and Gynecology, 193, 2071–2076. Miettinen, O., & Cook, E. (1981). Confounding: Essence and detection. American Journal of Epidemiology, 114, 593–603. Norton, C., Whitehead, W. E., Bliss, D. Z., Harari, D., & Lang, J. Conservative Management of Fecal Incontinence in Adults Committee of the International Consultation on Incontinence. (2010). Management of fecal incontinence in adults. Neurourology and Urodynamics, 29, 199–206. Offermans, M. P., Dumoulin, M. F., Hamers, J. P., Dassen, T., & Halfens, R. J. (2009). Prevalence of urinary incontinence and associated risk factors in nursing home residents: A systematic review. Neurourology and Urodynamics, 28, 288–294. Prado-Villanueva, B., Bischoffberger-Valde´s, C., Valderrama-Gama, E., Verdejo-Bravo, C., & Damia´n, J. (2011). Prevalence and main characteristics of urinary incontinence
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Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults Javier Jerez-Roig a,b,*, Dyego L.B. Souza c, Fabienne L.J.S. Amaral a, Kenio C. Lima a a Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil b Servicio de Rehabilitacio´n, Hospital Can Misses, Calle Corona s/n, 07800 Ibiza, Illes Baleares, Spain c Department of Collective Health, Federal University of Rio Grande do Norte, Campus Universita´rio s/n, CEP: 59078-970, Lagoa Nova, Natal-RN, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 May 2014 Received in revised form 4 February 2015 Accepted 6 February 2015 Available online xxx
The objective of this work is to determine the prevalence of FI and associated factors in institutionalized elderly. A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes (NHs) of the city of Natal (Northeast Brazil). Individuals over the age of 60 were included in the study, while those hospitalized or in terminal phase were excluded. Data collection included sociodemographic information, FI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity and Pfeiffer test for cognitive status). FI was verified through the Minimum Data Set (MDS) 3.0, which was also used to assess toileting programs. The Chi-square test and the linear Chisquare test were performed for bivariate analysis, as well as logistic regression for multivariate analysis. The final sample consisted of 321 elderly, mostly females, with mean age of 81.5 years. The prevalence of FI was 42.68% (CI 95%, 37.39–48.15). Most residents presenting FI were always incontinent (83.9%) and the most frequent incontinence type was total FI (solid and liquid stools). Incontinence control measures were applied only to 9.7% of the residents. The final model revealed a statistically significant association between FI and functional and cognitive impairments. It is concluded that FI is a health issue that affects almost half of the institutionalized elderly, and is associated with functional and cognitive disability. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aging Elderly NHs FI
1. Introduction Fecal incontinence (FI) is a common gastrointestinal complaint in elderly individuals, defined as the involuntary loss of stool or inability to control stool from expulsion, which is a social and hygienic problem (Norton, Whitehead, Bliss, Harari, & Lang, 2010; Shah, Chokhavatia, & Rose, 2012). Although it is a health issue frequently neglected, it affects between 2% and 20% of the elderly in community settings and prevalence increases considerably when an institution environment is considered (Aslan, Beji, Erkan, Yalcin, & Gungor, 2009; Leung & Rao, 2009; Leung & Schnelle, 2008; Saga, Vinsnes, Morkved, Norton, & Seim, 2013; Shah et al., 2012; Zarate, Lopez-Kostner, Vergara, Badilla, & Viviani, 2008). This problem entails a strong impact for health systems, as well as
* Corresponding author at: Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil. Tel.: +55 84 3215 4133; fax: +55 84 3215 4133. E-mail address: [email protected] (J. Jerez-Roig).
social impact to caregivers, family members, and on the health and life quality of the elderly (Leung & Rao, 2009; Shah et al., 2012). In Brazil, it is estimated that FI in the general population varies between 2% and 7%, however this figure may represent an underestimation of cases, due to the fact that the presence/ absence of the issue is auto-reported (Amaro et al., 2009; Santos & Santos, 2011; Santos et al., 2014). Controversy regarding the associated factors still remains for FI, and the subject has been the focus of limited research, especially in institutionalized elderly of Latin America (Santos et al., 2014; Townsend, Matthews, Whitehead, & Grodstein, 2013; Zarate et al., 2008). It is worth noting that continence control measures are not systematically applied in Brazil as in other developed countries such as USA, which could influence FI prevalence (Jerez-Roig, Souza, & Lima, 2013). Therefore the findings of this study contribute to the knowledge base on this specific health issue, frequent in older age groups and consequently, contribute to support prevention and control actions in a NH context. Thus, the objective of this study is to verify the prevalence of FI and associated factors in institutionalized elderly.
http://dx.doi.org/10.1016/j.archger.2015.02.003 0167-4943/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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2. Materials and methods 2.1. Subjects A cross-sectional study is presented herein, with data collection accomplished between the months of October and December 2013, in 10 of the 14 NH certified by the Sanitary Vigilance of the municipality of Natal (Northeast Brazil). The remaining 4 NH declined participation in the study. All elderly individuals were included in the study, i.e., over the age of 60, according to criteria from the World Health Organization (WHO) for developing countries. Exclusion criteria were: hospitalized or palliative care residents (terminal phase). The research team was constituted by the main researcher and by students from the undergraduate Physiotherapy course of the Federal University of Rio Grande do Norte (UFRN). The team met previously in two occasions, to ensure adequate comprehension of the questionnaires and calibration of examiners. A pilot study was carried out with 24 elderly from the first NH studied. The current study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte, approval no. 308/2012. 2.2. Measures The dependent variable of the study was the presence of FI, defined as ‘the involuntary loss of liquid or solid stool’, as accepted by the International Consultation on Incontinence (Norton et al., 2010). This information was extracted from item H4 of MDS version 3.0, which considers fecal continence during the previous 5 days, according to the direct caregiver. The following categories are possible: always continent, occasionally incontinent (1 episode of bowel incontinence), frequently incontinent (2 or more episodes), always incontinent (no episodes of continent bowel movements) and not rated (ostomy or no bowel movements for the entire 5 days). Residents with FI were selected when classified as occasionally, frequently or always incontinent for bowel movements. The MDS is a complete database for standardized assessment in NH, which has also presented high levels of reliability regarding continence status and toileting programs (Saliba & Buchanan, 2012). This tool was also used to assess urinary incontinence, devices (including ostomy), constipation and if bowel toileting programs were applied. Ostomy cases were accounted for, but were excluded from bivariate analysis. The direct caregiver also answered questions regarding the use of diapers and daily amount, classification of FI according to the type of feces (solid, liquid, or both) (Johanson, Irizarry, & Doughty, 1997), as well as the daily mean of bowel movements, presence of diarrhea and use of laxatives. A period of 5 days was considered to assess all variables regarding incontinence and bowel patterns (Saliba & Buchanan, 2012). Sociodemograhic variables were also collected (age, gender, race, education level, marital status, number of children and births, reason for institutionalization, residency time, free time occupation/hobbies, retirement, finance administration, health plan and ratio number of elderly per caregiver) as well as variables related to the NH (type of NH, length of stay and ratio residents/caregiver), and related to health conditions (presence and number of comorbidities, diabetes, cancer, prostate cancer, Parkinson’s disease, Alzeimer’s disease, stroke, arterial hypertension, kidney insufficiency, cardiovascular disease, pulmonary disease, osteoporosis, rheumatic disease, mental disease, vaginal, anal–rectal and prostate surgery records, consumption of alcohol, current and past consumption of tobacco, urinary infection within the last 30 days, hip fracture within the last 60 days, daily medication and number of medicines). All these variables were collected from medical records and complemented by information given by the main caregiver and healthcare professionals.
The mobility status was also considered (walks without aid, walks with aid, wheelchair user and bedridden) along with the functional capacity for activities of daily living (ADL), through the validated Portuguese version of the Barthel Index (Cincura et al., 2009), excluding the areas corresponding to continence, as described previously (Prado-Villanueva, Bischoffberger-Valde´s, Valderrama-Gama, Verdejo-Bravo, & Damia´n, 2011). Cognitive capacity was evaluated through Pfeiffer’s test, except for those with severe hearing deficit or those who did not speak the language (Martinez-Iglesia et al., 2001). 2.3. Analyses Bivariate analysis was carried out through the Chi-square test (or Fisher’s test) and the linear Chi-square test. The magnitude of association was verified through the prevalence ratio, to a significance level of 95%. Variables with p values lower than 0.20 were analyzed by logistic regression to build the multivariate model, through the Stepwise Forward method. Permanence of the variable in the multiple analysis depended on the Likelihood Ratio Test, absence of collinearity, as well as its capacity to improve the model through the Hosmer and Lemeshow test. Following Miettinen, odds ratio was transformed into prevalence ratio (Miettinen & Cook, 1981). 3. Results Of the total number of elderly, 8 (2.4%) of the individuals were excluded from the study: 6 (1.8%) were hospitalized, 1 (0.3%) was in terminal phase, and 1 (0.3%) was under the age of 60. A total of 321 elderly were included in the study (100% response rate), mostly of the female gender (75.4%) and the mean age was 81.50 (SD: 9.0). Of the total, 49.2% did not have children, 47.4% were single and 25.2% were widows/ers. The majority (63.3%) resided in not-forprofit organizations, and was institutionalized because of the lack of caregivers (46.7%) or because lived alone (13.4%). A total of 268 (83.5%) individuals were long-term stay residents (more than 1 year) and 16.5% were new admissions (up to one year). The mean residency time was 63.2 months (SD: 62.0) and the mean ratio elderly/caregiver was 8.09 (SD: 5.2). The majority of the elderly was retired (95.3%), however did not have private health plans (62.6%). The use of diapers comprehended 66.0% of the elderly and bowel toileting programs were applied to 31 residents (9.7%), through prompted voiding or facilitation of defecation by the use of laxatives. Of the total number of elderly, 40 presented constipation (12.5%), 9 presented diarrhea (2.8%), and 31 used laxatives (11.5%). The daily mean of bowel movements was 1.2 (SD: 0.8). FI prevalence was 42.68% (CI 95%, 37.39–48.15), and there was 1 (0.3%) unclassified case (colostomy). Among the 137 elderly with FI, double (fecal and urinary) incontinence was observed in 135
Table 1 Characteristics of the residents presenting FI (n = 137).
Frequency Occasionally incontinent Frequently incontinent Always incontinent FI type Solid stool Liquid stool Total Bowel toileting program No Yes
n
%
7 15 115
5.1 10.9 83.9
42 14 81
30.7 10.2 59.1
129 8
94.2 5.8
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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Table 2 contains the variables that presented p value equal or lower than 0.20 in the bivariate analysis and were not included in the final model. Multiple analysis showed that FI was associated with functional and cognitive incapacities, assessed by the Pfeiffer scale, adjusted by the variables age, race, stroke, and reason for institutionalization ‘‘lack of caregiver’’ (Table 3). This re-categorization of the variables functional and cognitive incapacities occurred due to a low frequency of FI cases presenting functional independency and intact cognitive capacity. The Hosmer–Lemeshow value was 0.930.
(42.1%) individuals, and only 2 (0.6%) did not present urinary incontinence. The majority of the elderly with FI presented the total type (solid and liquid stool), was always incontinent (not presenting any episode of continence), and did not follow any continence control program. The characteristics of the elderly presenting FI are shown in Table 1. It is worthwhile to mention that in the FI group there were no cases of functional independency, and only one case of slight dependence. For this reason, it was decided to group the categories independency, slight and moderate dependency.
Table 2 Bivariate analysis of the FI associations with independent variables. FI No
Yes
Gender Male Female Marital status Married Other Arterial hypertension Yes No Education level Illiterate-Primary Education I Primary Education II-Superior Daily frequency of bowel movements <2 2 Reason for institutionalization: lived alone No Yes Reason for institutionalization: own choice Yes No Physical activity Yes No Occupation Yes No Consumption of alcohol No Yes Consumption of tobacco No Yes Alzheimer’s disease No Yes Rheumatic disease No Yes Mental disease No Yes Urinary incontinence No Yes Use of laxants No Yes Mobility Walks without aid Walks with aid Wheelchair Bedridden a b c *
n
%
n
33 104
41.8 43.2
46 137
58.2 56.8
0.830a
1 1.03 (0.77–1.39)
22 110
55.0 41.0
18 158
45.0 59.0
0.096a
1 0.75 (0.54–1.02)
45 92
32.6 50.5
93 90
67.4 49.5
0.001a,*
1 0.64 (0.49–0.85)
56 54
37.1 46.2
95 63
62.9 53.8
0.134a
1 1.24 (0.93–1.66)
92 42
40.7 59.2
134 29
59.3 40.8
0.006a,*
1 1.45 (1.13–1.86)
117 12
44.0 27.9
149 31
56.0 72.1
0.047a,*
1 0.63 (0.38–1.04)
0 129
0 43.0
9 171
100.0 57.0
0.037b,*
1 1.75 (1.59–1.94)
7 130
11.9 49.8
52 131
88.1 50.2
<0.001a,*
1 4.20 (2.07–8.50)
28 108
24.8 52.4
85 98
75.2 47.6
<0.001a,*
1 2.12 (1.50–2.99)
136 1
44.0 10.0
173 9
56.0 90.0
0.048b,*
1 0.28 (0.03–1.46)
133 4
45.2 16.0
161 21
54.8 84.0
0.005a,*
1 0.35 (0.14–0.88)
90 47
36.7 62.7
155 28
63.3 37.3
<0.001a,*
1 1.71 (1.34–2.17)
135 2
44.4 12.5
169 14
55.6 87.5
0.012a,*
1 0.28 (0.78–1.03)
115 22
46.0 31.4
135 48
54.0 68.6
0.029*
1 0.68 (0.47–0.99)
2 133
1.6 70.7
127 55
98.4 29.3
<0.001a,*
114 22
40.7 59.5
166 15
59.3 40.5
0.030a,*
11 24 46 56
8.7 37.5 70.8 87.5
116 40 19 8
91.3 62.5 29.2 12.5
<0.001c,*
%
p
PR (CI 95%)
1 45.63 (11.50–181.05) 1 1.46 (1.08–1.97) 1 4.33 (2.27–8.27) 8.17 (4.54–14.68) 10.10 (5.70–17.90)
Chi-square test. Fisher test. Linear trend Chi-square test. Statistically significant.
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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Table 3 Bivariate (Chi-square test) and multiple analysis of the FI associations with independent variables included in the final model. FI No
Yes n Age 50 60–80 81 87 Race Other 57 White 80 Reason for institutionalization: lack of caregiver 52 No Yes 77 Stroke No 100 Yes 37 Functional capacity 21 Independence, low dependence and moderate dependence 116 High dependence Cognitive capacity (Pfeiffer) Intact/Slight and moderate decline 18 Severe decline 116 *
%
n
%
p
PR (CI 95%)
p
Adjusted PR (CI 95%)
35.7 48.3
90 93
64.3 51.7
0.024*
1 1.35 (1.03–1.77)
0.569
1 1.13 (0.74–1.71)
38.3 46.8
92 91
61.7 53.2
0.124
1 1.22 (0.94–1.58)
0.088
1 1.37 (0.95–1.97)
32.5 51.7
108 72
67.5 48.3
0.001*
1 1.59 (1.21–2.09)
0.251
1 1.27 (0.84–1.92)
37.3 71.2
168 15
62.7 28.8
<0.001*
1 1.91 (1.51–2.41)
0.674
1 1.12 (0.65–1.93)
12.4
149
87.6
<0.001*
1
77.3
34
22.7
15.8 61.4
96 73
84.2 38.6
<0.001*
6.26 (4.16–9.43) <0.001*
1 3.89 (2.51–6.03)
1 5.82 (3.78–8.95)
<0.001*
1 3.16 (1.91–5.20)
Statistically significant
4. Discussion From the results of this research, it was observed that almost 43% of the institutionalized elderly presented involuntary losses of feces, a prevalence value that agrees with the ranges presented in literature, which generally vary between 33% and 65% (Saga et al., 2013; Shah et al., 2012; Zarate et al., 2008). However, the severity of the incontinence in this sample was higher, considering that most residents with FI did not present any episodes of continence, with liquid and solid stool losses (Aslan et al., 2009). Therefore, there are few ‘‘light’’ forms of FI, which suggests that institutionalized elderly decline rapidly until losing complete control of sphincters. Despite the high prevalence values, incontinence control measures are applied to a minority of residents, mostly in private NH. This proportion is lower than that reported by other studies and corroborates the fact that only a minority of institutionalized elderly in Brazil are exposed to specific continence therapies (Jerez-Roig et al., 2013; Prado-Villanueva et al., 2011; Roe et al., 2011). Although the objective of this study was not to evaluate the effectiveness of the interventions applied to institutionalized elderly, it must be highlighted that some studies demonstrate the effectiveness of toileting programs in the improvement of constipation and incontinence (Leung & Rao, 2009; Schnelle et al., 2010, 2009). Although FI frequency was higher in older individuals and slightly superior in women, this association did not present significance in the final model, when adjusted by other variables. While several studies carried out in community settings show the association of FI with age and the female gender, the findings of this study reveal that health conditions seem to be more relevant than sociodemographic characteristics in NH settings (Ditah et al., 2014; Melville, Fan, Newton, & Fenner, 2005; Shamliyan et al., 2009; Whitehead et al., 2009). No association was verified between the variables related to NH, such as the length of stay, and FI, which could be due to the fact that elderly in Brazil are not commonly institutionalized for a short recovery period of time with the objective of returning to the community, and frequently the elderly are already admitted in a general poor health state (Jerez-Roig, Santos, Amaral, & Lima, 2015).
The results of the multivariate analysis showed the relationship of FI with severe dependency for ADL and severe cognitive impairment, when adjusted by age, race, stroke and reason for institutionalization ‘‘lack of caregiver’’. Both geriatric syndromes are widely studied in literature and are placed among the most important factors associated with FI, in institutionalized elderly as well as those living in community settings (AlAmeel, Andrew, & MacKnight, 2010; Aslan et al., 2009; Burge, von Gunten, & Berchtold, 2013; Melville et al., 2005; Saga et al., 2013; Shamliyan et al., 2009; Townsend et al., 2013). The prevalence of functional impairment was high in this study: almost 80% of the residents presented some type of functional dependency for ADL, and half of these cases presented total dependency. Functional incapacity is considered to be an important predictor of institutionalization, even stronger than FI, which indicates that a considerable proportion of the elderly is already admitted with an important deterioration of ADL (AlAmeel et al., 2010). Presence of FI is considered a marker of poor health status and can indicate an advanced process of health deterioration (AlAmeel et al., 2010). Longitudinal studies show that incontinence is one of the contributing factors to the decline of functionality for ADL, during the period of residence of the elderly (Burge et al., 2013; Wang, Kane, Eberly, Virnig, & Chang, 2009). Specifically, tasks such as locomotion and use of bathroom are strongly correlated to FI (Saga et al., 2013). In this way, the resident can develop functional incontinence, due to the incapacity to reach the bathroom in a timely fashion, due to mobility problems or due to cognitive decline (Aslan et al., 2009; Saga et al., 2013; Townsend et al., 2013). The relationship between functional incapacity and FI can also be explained by the multifactorial etiology theory of geriatric syndromes, which regards loss of compensatory ability when multiple physical and psychocognitive domains are affected (CollPlanas, Denkinger, & Nikolaus, 2008). Besides, functionality is related to deficits in muscle strength and physical inactivity, which accompany the natural aging process, and can limit significantly the autonomy of the elderly. In this sample, the prevalence of sedentarism was elevated, which is a fact that can contribute to mobility constraints and loss of sphincter control (Coll-Planas et al., 2008; Townsend et al., 2013). In this study,
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
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physical inactivity and immobility lost statistical significance when adjusted in the multivariate model. Regarding chronic diseases, it has already been reported that the increase in FI prevalence in the elderly is not explained by the higher presence of comorbidities (Shah et al., 2012). In this study, there were no associations between chronic diseases and FI, and only stroke was present in the multivariate model, as an adjustment variable. Neurological diseases, such as stroke or Alzeimer’s, are broadly cited in literature as variables that can be directly associated with cognitive incapacity, which in turn resulted to be an important factor associated with FI (Aslan et al., 2009; Santos et al., 2014). Cognitive incapacity is a geriatric syndrome highly prevalent in institutionalized elderly: more than 90% of the participants of this study presented some form of cognitive decline and more than 60% presented severe decline. The association between dementia and FI has been identified as one of the most strongly associated with incontinence in the elderly, as it can affect the capacity of reaching the bathroom rapidly. Besides, cognitive decline is considered a predictor of functional incapacity and mobility, which, in turn, can contribute to the development of incontinence (Hatta, Iwahara, Ito, Hatta, & Hamajima, 2011; Leung & Rao, 2009; Offermans, Dumoulin, Hamers, Dassen, & Halfens, 2009). In this study, the majority (98.5%) of the FI residents presented dual incontinence (both urinary and fecal involuntary losses) and, therefore, the association between both types of incontinence was significant in the bivariate analysis. Although this association has already been reported by several authors, the low frequency of cases prevented the permanence of the variable in the multivariate model (Amaro et al., 2009; Aslan et al., 2009; Ditah et al., 2014; Townsend et al., 2013). Medical history of births and surgeries in the pelvic area did not present significant association with FI, as found in studies carried out within the community (rather than in NH environments) (Amaro et al., 2009; Santos et al., 2014). Still, it must be recognized that, as a limitation of the study, some comorbidities could have suffered under-registry, due to the lack of information contained in medical records and low number of diagnosis established in the residents. Furthermore, the Pfeiffer test is currently not validated to the Portuguese language and a validated translation to the Spanish language was employed. The choice was justified by the fact that other instruments, such as the Mini-Mental State Examination, are more exigent for institutionalized elderly populations and require longer applications times, which prevents epidemiological research to be carried out. It must be mentioned that the cross-sectional design of this study does not allow for the establishment of a cause-effect relationship between the variables and, therefore, some of the findings must be interpreted with caution. The present study is remarkable due to the high number of analysis variables and also due to the high representativity of the sample, obtained through participation of the majority of NH in Natal (Northeast Brazil) and through reduced losses, lower than 6% for all analysis variables. After systematic reviews and to the best of the author’s knowledge, this is the largest research carried out in Latin America on FI in NH environments.
5. Conclusions It can be concluded that FI is a health issue that is prevalent in the NH environment, affecting almost half of the institutionalized elderly. Despite the high prevalence and high severity of the issue, incontinence control measures are applied with low frequency and almost exclusively in private NH. Prevalence of FI was similar as found in other countries, but the severity of the continence verified herein was higher.
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Functional and cognitive incapacity were highly associated with FI, showing the strong association between these two geriatric syndromes and loss of continence. Since these are modifiable and preventable health issues, this finding suggests that these factors must be taken into consideration when planning continence control programs for institutionalized elderly. Due to the fact that fecal continence is one of the last affected capacities in individuals undergoing health decline processes, the loss of continence can be considered an alarm signal that should be avoided or prevented at all costs, aiming at delaying, as much as possible, functional dependency and improving life quality of the elderly. Conflict of interest None declared. Source of funding None declared. References AlAmeel, T., Andrew, M. K., & MacKnight, C. (2010). The association of fecal incontinence with institutionalization and mortality in older adults. American Journal of Gastroenterology, 105, 1830–1834. Amaro, J. L., Macharelli, C. A., Yamamoto, H., Kawano, P. R., Padovani, C. V., & Agostinho, A. D. (2009). Prevalence and risk factors for urinary and fecal incontinence in Brazilian women. International Brazilian Journal of Urology, 35, 592–598. Aslan, E., Beji, N. K., Erkan, H. A., Yalcin, O., & Gungor, F. (2009). The prevalence of and the related factors for urinary and fecal incontinence among older residing in nursing homes. Journal of Clinical Nursing, 18, 3290–3298. Burge, E., von Gunten, A., & Berchtold, A. (2013). Factors favoring a degradation or an improvement in activities of daily living (ADL) performance among nursing home (NH) residents: A survival analysis. Archives of Gerontology and Geriatrics, 56, 250–257. Cincura, C., Pontes-Neto, O. M., Neville, I. S., Mendes, H. F., Menezes, D. F., Mariano, D. C., et al. (2009). Validation of the national institutes of health stroke scale, modified rankin scale and Barthel Index in Brazil: The role of cultural adaptation and structured interviewing. Cerebrovascular Diseases, 27, 119–122. Coll-Planas, L., Denkinger, M. D., & Nikolaus, T. (2008). Relationship of urinary incontinence and late-life disability: Implications for clinical work and research in geriatrics. Zeitschrift fur Gerontologie und Geriatrie, 41, 283–290. Ditah, I., Devaki, P., Luma, H. N., Ditah, C., Njei, B., Jaiyeoba, C., et al. (2014). Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005–2010. Clinical Gastroenterology and Hepatology, 12, 636–643. Hatta, T., Iwahara, A., Ito, E., Hatta, T., & Hamajima, N. (2011). The relation between cognitive function and UI in healthy, community-dwelling, middle-aged and elderly people. Archives of Gerontology and Geriatrics, 53, 220–224. Jerez-Roig, J., Santos, M. M., Amaral, F. L. J. S., & Lima, K. C. (2015). Prevalence of urinary incontinence and associated factors in nursing home residents. Neurourology and Urodynamics (in press) (http://onlinelibrary.wiley.com/doi/10.1002/nau.22675/ abstract). Jerez-Roig, J., Souza, D. L., & Lima, K. C. (2013). Incontineˆncia urina´ria em idosos institucionalizados no brasil: Uma revisa˜o integrativa. Revista Brasileira de Geriatria e Gerontologia, 16, 865–879. Johanson, J. F., Irizarry, F., & Doughty, A. (1997). Risk factors for fecal incontinence in a nursing home population. Journal of Clinical Gastroenterology, 24, 156–160. Leung, F. W., & Rao, S. S. (2009). Fecal incontinence in the elderly. Gastroenterology Clinics of North America, 38, 503–511. Leung, F. W., & Schnelle, J. F. (2008). Urinary and fecal incontinence in nursing home residents. Gastroenterology Clinics of North America, 37, 697–707. Martinez-Iglesia, J., Duenas-Herrero, R., Onis-Vilches, M. C., Aguado-Taberne, C., AlbertColomer, C., & Luque Luque, R. (2001). Spanish language adaptation and validation of the Pfeiffer’s questionnaire (SPMSQ) to detect cognitive deterioration in people over 65 years of age. Medicina Clinica, 117, 129–134. Melville, J. L., Fan, M. Y., Newton, K., & Fenner, D. (2005). Fecal incontinence in US women: A population-based study. American Journal of Obstetrics and Gynecology, 193, 2071–2076. Miettinen, O., & Cook, E. (1981). Confounding: Essence and detection. American Journal of Epidemiology, 114, 593–603. Norton, C., Whitehead, W. E., Bliss, D. Z., Harari, D., & Lang, J. Conservative Management of Fecal Incontinence in Adults Committee of the International Consultation on Incontinence. (2010). Management of fecal incontinence in adults. Neurourology and Urodynamics, 29, 199–206. Offermans, M. P., Dumoulin, M. F., Hamers, J. P., Dassen, T., & Halfens, R. J. (2009). Prevalence of urinary incontinence and associated risk factors in nursing home residents: A systematic review. Neurourology and Urodynamics, 28, 288–294. Prado-Villanueva, B., Bischoffberger-Valde´s, C., Valderrama-Gama, E., Verdejo-Bravo, C., & Damia´n, J. (2011). Prevalence and main characteristics of urinary incontinence
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Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003