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The Incontinent Patient: A Roundtable Discussion
R. David Cobb, PharmD
Michael L. Freedman, MD
The
Incontinent Patient A Roundtable Discussion Roger Andersen, RPh
Alan Shubin, RPh
U
rinary incontinence is a problem many people-both patients and health professionals alike-are hesitant to discuss. Yet an estimated ten million Americans have bladder control problems, and 50% of all American women will experience some form of incontinence during their lives. The problem can drastically affect how people lead their lives. For the young, it cari lead to reclusive behavior. For the elderly, it can lead to a complete loss of independence. Incontinence, in fact, is the fifth leading cause of admissions to nursing homes. Despite the humiliation and withdrawal from society urinary incontinence can cause, it is curable in 30% of the cases and manageable in 100% of the cases. With the increasing
American Pharmacy Vol. NS24, No. 6, June 1984/351
Dorothy P. Goodman, RN
number of convenient, comfortable, absorbent products on the market, there is no need for the incontinent patient to lead less than a full, active life. The pharmacist has an important role in providing patients with the facts about incontinence and in providing appropriate products with which they can manage the prob-
lem. The pharmacist should also be aware of various drugs that can cause incontinence and be prepared to refer the patient for medical treatment when warranted. American Pharmacy invited a panel of health professionals with special knowledge about the incontinence field to share their observations with our readers. The participants were: • R. David Cobb, PharmD, moderator, president of APhA's Academy of Pharmacy Practice and associate professor at the University of Kentucky College of Pharmacy, Lexington. Cobb also works regularly in a community pharmacy serving a large population of ostomy and incontinent patients. • Michael L. Freedman, MD, director of the Division of Geriatric Medicine and the Center for Care of 31
the Elderly-Research and Education at the New York UniversityBellevue Medical Center, and professor at New York University School of Medicine. He is founder of one of the nation's first and largest comprehensive geriatric clinics at Bellevue Hospital in New York. Freedman is a consultant to many corporations and universities, including Kimberly-Clark. • Roger Andersen, RPh, director of the Home Health Care Center, Peoples Drug Stores, Washington, DC. A former owner of several community pharmacies and a pharmacy consultant for Medicare and Medicaid, Andersen has also operated a group of five home health care centers. • Dorothy P. Goodman, RN, an enterostomal therapist with the Visiting Nurse Association of Northern Virginia, Arlington, VA. Goodman has had extensive experience with elderly and incontinent patients. • Alan Shubin, RPh, owner of The Omni Pharmacy, a full service community pharmacy in Alexandria, VA, which includes ostomy and incontinent supplies as special features. Shubin is also a pharmacy consultant to the Mt. Vernon Nursing Center in Alexandria. American Pharmacy acknowledges the support of Kimberly-Clark Corporation in convening this roundtable. Cobb:
Incontinence is one of those things that's not talked about a lot, and I think many pharmacists are just now beginning to realize how large a problem it really is. It's important for us to convey to the pharmacist what the problem isfrom both a medical and a psychological standpoint-and how the pharmacist can better help this type of patient. Let's get a feel for the medical problems, and talk about how this patient differs from the one who walks in and says, "I've got a cold. What do you have for it?" Freedtnan:
Let me tell you how I got interested in the urinary incontinence
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field. We were doing a study a few years ago on urinary tract infections in older women, and we devised a questionnaire looking for people who had urinary tract symptoms. One of the questions asked if the person was incontinent. We discovered that about 3040% of our patients were incontinent of urine and had never told us. When directly asked, they seemed to be relieved that someone had finally asked them, and it
'Taken as a medical problem, you're dealing with a condition that in about 70% of the cases has to be managed rather than treated.' turned out we had sort of opened up a can of worms in this large group of ambulatory care patients, who all of a sudden were coming to us once the word got out that we were interested in urinary incontinence. As we began to look at the literature on the problem, we found that as a medical problem, about 10% of the population over age 65 and about 30% of the population over age 80 is incontinent. This amounts to about 3 million people. But there are also about another 7 million people under the age of 65 in this country who have at least some degree of incontinence. Incontinence can be divided into five major areas by symptomatology. The first is so-called urge incontinence, where the patient constantly has to go to the bathroom. This can be caused by reversible conditions such as urinary tract infections, bladder stones, bladder tumors, urethritis, and inflan1mation of the urethra. In older people, however, it's often caused by the instability of the bladder muscle-specifically, de-
trusor muscle instability. Here it's a phenomenon of aging and in many instances is not curable. The second type of incontinence is stress incontinence. This is very, very common throughout the female population, and, in fact, 50% of all women will at one time or another experience some degree of stress incontinence. When you laugh or cough or sneeze, you lose a few drops of urine. In women, this is due to the short urethra and to multiple childbirths. In older women, it's often because the gynecologist has done a hysterectomy. It can also be caused by infection, and is sometimes seen in men with prostate problems. The third type is overflow incontinence. We see this in men when their prostates get large and there is an obstruction to the outflow of urine. The patient will constantly complain of dribbling even after they've urinated. The bladder can't empty. It can also happen in women due to bladder neck hypertrophy with age. Even though women don't have a prostate, the area where they would have had a prostate if they were men still can hypertrophy. These are usually correctable, but the older you get the less correctable it's going to be. A fourth type is reflex incontinence. We see it with spinal cord injuries where there's some kind of irritation to the spinal nerves coming to the bladder·, and it usually results in total incontinence. Then there's a fifth type commonly seen in institutions and nursing homes called functional incontinence. There's really nothing wrong with the urinary tract, but the patient just can't get to the . bathroom in time. You see this especially in a city like New York when you're dealing with some of our big institutions where there's always a great nursing and nursing aid shortage. The older patient has the side rails up and they can't get to the bathroon1, so they ring for a bedpan and there's a 15 or 20 n1inute delay. These patients aren't really
American Pharmacy Vol. NS24, No. 6, June 1984/352
think a lot of them just accept it because they think it's something that's supposed to happen to them because they're old. These are the people I worry about. They're old and they're scared to go out, anyway, and then they become incontinent and they're even more scared to go out. We lose track of them. I see our biggest chance for contact with them when they go into a pharmacy, or someone else goes into a pharmacy for them, and they're buying diapers, dressings, creams, and equipment like that. Somebody might be alert enough to come over and say, "Is there something I can help you with? I see you're buying a lot of ·equipment." In this way, maybe we can get these people into the stream of what's going on. Cobb:
I've got a quick question-does the word incontinence mean anything to the average person? Freedman: No, not a thing. When we were doing our questionnaire, we were very surprised to find the average person has no idea what it means. Our questions were much more direct: Do you have trouble controlling your urine or bladder? Shubin:
Freedman
incontinent if you could get them to the bathroom on time. If you take .all of these incontinent patients, we could probably cure about 20-30 % of them. So taken as a medical problem, you're dealing with a condition that in about 70 % of the cases has to be managed rather than cured. Goodman: I corne across two types of patients who are incontinent. One is the
American Pharmacy Vol. NS24, No. 6, June 1984/353
person who has been in the hospital for some reason and may have had some kind of surgery. They're usually elderly, and while they're in the hospital I treat them with catheters. When they come out, they're still incontinent. Luckily, most of these people are under medical care, so they're being treated and followed up on. The other type of patients are those who suddenly find them-. selves becon1ing incontinent. I
I think it's important to raise the fact that we're talking about a quality of life issue. With the elderly, it can restrict their activities to an extent where they may end up staying in the house, and not going out for fear of not being able to get to a bathroom or of wetting their clothes or creating an odor. Number one, they might not recognize the problem, and, number two, they may not know what to do about it. A lot of the senior citizens I come into contact with seem to have recurrent urinary tract infections. What typically happens is they can't get out of their apartments to actually go see a doctor because there's no transportation,
33
so they pick up· the phone and call the doctor's office, whereupon the doctor puts them on the appropriate regin1e for UTis and there will be tetnporary relief for a few days. Meanwhile, they're still sitting in their aparttnent, they're still afraid to go outside, and when they do go outside they may have an accident. Yet they're reluctant to admit to anyone that there's something wrong here. I think this is one place the pharmacist is important because the phannacist can show that he or she is accessible to issues of this sort. One thing that really struck me was that over the Christmas holidays I had a woman come into my pharmacy who was searching for a way that would allow her mother to feel like she could travel down here to visit. The reason Mom didn't want to leave the house was because she was afraid she couldn't make the car ride. What could she do? Cobb:
Incontinence is obviously a medical condition-there's nothing intentional about it. Yet there seems to be a real stigma attached to it. There's the feeling that it is a terrible thing to wet your pants out in public. Why is this? Is it because it seems so childish for a grown person to have this problem? Freedman:
We're a very cleanliness-oriented society, and probably overly so. This problem is seen as a great loss of control. It's something that is not culturally accepted. The Association of American Medical Colleges has listed the "Five I'_s" that every physician should be aware of in terms of the elderly. These are impaired homeostatis-trouble with just maintaining health; immobility-trouble with bones and joints; incompetence-Alzheimers and dementia; iatrogenic disease-trouble with drug therapy; and then, incontinence. If you look at these five major 34
Goodman
areas, patients aren't reluctant to talk to you about any of the other four. Incontinence is the only one that's really embarassing to them. I mean, no patient worries about coming in to tell you their shoulder hurts. Cobb:
I've discovered that I have no trouble with ostomy patients because there is a declared medical
condition there. They've had surgery; they've had something done to them. It seems to be all right. But it's different with incontinence. It seems a little bit like VD. It used to be unacceptable to talk about VD. At least with VD you understood that you probably did something wrong to catch it. But in this case you haven't done anything wrong and you're incontinent.
American Pharmacy Vol. NS24, No. 6, June 1984/354!
Goodman: There's a good deal of emphasis on ostomy anymore; ostomates are a recognized population and they have groups they can go to for support and to talk about their problems. That's why most of them aren't hesitant in bringing up the subject. I don't think the incontinent population feels that way. Freedman:
the field as far as the pharmacist is concerned, being a practitioner in the private field and also in the home health field. I can remember in the '70s when ostomies and incontinence were hardly ever discussed, and it was only the specialized pharmacies that even handled the ostomy and incontinence products. Incontinence has now evolved into such a big field that I think it's running parallel with the os-
tomy products. I find ·many more people coming in and inquiring about incontinence products, even though I rarely run across someone who admits they have this particular problem. As the field has evolved, there has been a big diversification of products, and it requires qualified people who are able to explain what's available and how to use the products. In terms of pharmacy at the
A story that's germane to this discussion is how Kimberly-Clark got into this whole disposable undergarment business. Back during World War I, they got a contract to make paper wadding used in shipping guns overseas. Some of the American nurses in Europe discovered that this paper was very good for cleaning up blood in the operating room. One of the nurses then got the bright idea that it would also be good for when you would menstruate. At that point in the history of the world, there had never been anything devised for menstruation, and most women would just stay home-they'd be sick for one week every month. When this nurse came back to Wisconsin, she told somebody about the paper, and Kimberly-Clark got the wonderful idea to 1nanufacture Kotex. What they did, essentially, was to take a medical condition-because you were home one week a month while you were a young woman-and turn it into a nonmedical condition. The point is that we could do something like this with urinary incontinence. Most of the time, it doesn't have to impair our daily life. The key to it is patient education, and to make people realize that of all the problems you can get as you go through life, incontinence is one of the minor ones. We may have trouble curing it, but we really don't have any trouble managing it. Andersen:
I can give you a quick feeling for
American Pharmacy Vol. NS24, No. 6, June 1984/355
Andersen
35
community level, you have to have a training program for the person who's going to handle the problem. You can't just put it on a self-service basis. Even though there are some products that are doing national advertising, they represent just a limited part of the incontinence field. Freedman: 1 was at a party recently with two
friends of mine. One is a pharmacist and one is a doctor practicing in my home town. The two of them were talking about incontinence and the pharmacist said, "There's an unbelievable number of people coming into the pharmacy complaining of incontinence," and the doctor practicing in the same area said, "Really? I don't see any patients at all for that." I think this paints out that people are looking to the pharmacist for help because he or she is less threatening than the physician. A problem I see is that as national advertising for incontinent products picks up, the emphasis on selling the product may make it more difficult to find the 30% of patients who are curable. The pharmacist should understand that he's an important resource and should encourage his patients to undergo a thorough workup at least somewhere in the course of the illness so we don't miss that 30%.
Shubin: I couldn't agree with you more. I think the issue as far as the pharmacist is concerned is the pharmacist's accessibility and willingness to make himself or herself available to the patient to discuss these issues. I agree completely with Roger when he says you need a training program. If a large chain decides to make these products available, they should give some guidance to the pharmacist, and even give some guidance to the clerks, to make them aware that because there is a patient population who may be reluctant to talk about this,
36
'You have to have a training program for the person who's going to handle the problem. You can't just put it on a selfservice basis.' pharmacists should make themselves available. The key issue is accessibility. It's easier to be accessible in my practice setting, simply because it's small and intimate. But I don't think we should, or have to, relieve the chains of this responsibility. Freedman: The patient we're all missing is the young woman who has some amount of stress incontinence. She's going in and buying panty liners or menstrual pads for this, and we're not giving her any kind of education or treatment that could prevent further problems. Andersen: An interesting fact about this field is that in the years I've been running ads for various home health products, the responses for incontinent products have far exceeded those for any other item, whether it's diabetic or something else. We've run ads on new types of incontinent underpads, and not just strictly on price but on the fact that they're available, and our response generally runs higher than on all other categories. I think the reason is that there are a lot of people who see the ad and say, "I fit into that category. Here's somebody that knows about it." It proves to me that there are a lot more people interested in incontinent products than in durable medical equipment or some of the other programs we've had. Cobb:
We all seem to agree that the
pharmacist is the most available health professional and it's logical that we're the people to do a lot of this work with the incontinent. Yet I don't think most pharmacists know how to proceed. How do you start in this field? Andersen: We've done a survey in the Washington DC area and we've found very little distribution of incontinent products in either chains or independent pharmacies. You find one, two, or three products, and that's the maximum. In fact, I'd say that over 50% of the stores don't have three incontinent products. They take on one or two of the national products that are on a self-service basis. I think pharmacists are aware of the products, but it seems to be a matter of inventory and time. It generally takes a good five or ten minutes for a consultation with an incontinent patient, to let them know what's available and so forth, and can sometimes take as long as half an hour. Also, there is such a variety of items available that the community pharmacist faces an inventory problem, in terms- of initial stocking, continuous flow of inventory, what's available, and so on. It's interesting to compare this with the diabetic field. There are about 10 million diabetics in the U.S. and there are at least 10 million incontinent patients .in the U.S. Most of the pharmacies have an involvement in diabetes-insulin and so forth-and are knowledgeable about the problem, while few pharmacies are really into the incontinent field. Yet if anyone ever made an indepth study on it, I'm quite sure they'd find that the monetary aspect of incontinent patients is the same, if not more, than with the diabetic patient. ·The problem i that it's not as easy a field to get into. There's more of a monetary outlay in getting involved. There's more involvement in term of inventory and training. You ha e to have literature a ail ble.
American Pharmacy Vol. NS24, No. 6 , June 1984/3SS
While I agree the pharmacist is the logical person to come to with the first questions about incontinence, I don't think you're going to find a large number of pharmacies approaching it as one of their main features. Not that it shouldn't be, but that's how it is. Goodman: I don't think you really need a big inventory to start. The important part is to have patients come into the pharmacy with their questions and to have their questions answered. The commercial says, "Ask your pharmacist." I think that's great. By asking the questions, these people can be steered back into the system. It's not necessary to have all the supplies right there. As a matter of fact, I really don't like to see a lot of ostomy and incontinent supplies out on anybody' s shelves because I don't want to see people just going in and buying these things. We run the risk of the patient not having the condition
American Pharmacy Vol. NS24, No. 6, June 1984/357
properly diagnosed. Freedman: There's been some talk today of self-catheterization and that's something that shouldn't be forgotten. It's a very important technique, especially in younger people. You have almost no infection rate with intermittent self-catheterization, and people can learn to do it-they don't mind learning to do it. The pharmacist can suggest this as an option, or at least suggest that the patient take it up with his physician. The pharmacist should also keep in mind that a number of medications can contribute to urinary incontinence-especially a lot of the things that are bought over the counter, like anticollagenase products and the antihistamines people are buying like crazy. There are many scenarios with a lot of these ore medications, and it's the role of the pharmacist to warn people, especially the elderly, about these
side effects. And if one week the pharmacist sees somebody buying benadryl to sleep and two weeks later the patient is coming in to buy incontinent pads, the pharmacist should make the connection. There are a lot of simple things to watch out for that people often don't consider. Many women are now taking calcium supplements for osteoporosis, and it's probably a good idea. But you've also got to remember that hypercalcemia can lead to diuresis and that can be a reason somebody becomes incontinent. Cobb: That's a good point. Now, I have no problem in saying to a patient that this may color your urine red. But how do you tell them this may cause them to wet their pants? Suddenly I get very uncomfortable because I don't deal with this on a daily basis. How do you handle that? What's the correct approach? 37
person comes up with a question. To me, it boils down to establishing the notion and the image that the pharmacist is (1) an acces-sible person, and (2) the appropriate person to ask about OTC products. We've come a long way in getting pharmacists to understand that their job is not simply to count pills, type labels, and say, "Thank you. That's $5.95." We want the notion that pharmacists are drug information providers to become pervasive. As the public comes to understand that, things will be better. Cobb: How does the pharmacist who understands very little about incontinence get started? What's the minimum in terms of products you have to stock?
Shubin
Shubin: I'm not sure I know the answer. One of the li.mitations we all have with a person walking into the pharmacy is that we don't know their medical history until they tell us about it. To be perfectly honest, most times when I sell OTC products I don't say anything unless it's an obvious situation, such as when someone has hypertension and is buying a decongestant. I don't 38
know how you overcome this unless people go to the same pharmacy all the time and establish a relationship with the pharmacist, and I'm not sure that's always the case. The self-service aspects of a lot of pharmacies is a disadvantage here. Most people who walk into a pharmacy to buy whatever OTC thing they want don't get within 40 yards of a pharmacist. The only way the pharmacist is going to interact with that person is if the
Shubin: I agree with what Dot said earlier about it not being necessary to immediately stock each and every incontinent product that is on the market. Roger's point is well taken, too, that inventory costs can be a real problem for a community pharmacist. That's definitely an issue. But I don't think it's necessary to stock every product. In my store, I carry one of the disposable products; I carry another line of more elaborate incontinent pant; I carry some condom catheters; and I have some leg bags, some extension tubing, and a couple of Foley catheters-but I don't use them on the ambulatory patient, obviously. For the rest, most pharmacists have the advantage of 24-hour delivery service from their wholesaler. Should they need something, they can always get it the next day. Many pharmacists also have interrelationships with other drug stores in the area should they need something quickly. So I think the minimum one needs to carry is a good, convenient disposable product, perhaps a more elaborate set of incontinent pants with a liner, and then when
American Pharmacy Vol. NS24, No. 6, June 1984/358
you get into the area of condom catheters and leg bags, I think you can play that by ear. You'll want to see the kinds of people who are coming into your store for these and the kinds of particular problems you're going to be faced with. The first part of your question is more difficult to answer. If you want to get involved in this area but have no knowledge: what do you do? I'd like to be able to say we came out of school with some basic knowledge about subjects like incontinence, but that's not the case for the most part. People like Dot are probably the best resource around, and are underutilized by pharmacists. Most pharmacists don't even know what ETs are, especially if they don't deal with ostomates. Another thing to do is identify the companies that provide these products and write to them for information. There's a wealth of information available from them. A simple way to get an overview is to pick up a catalog of any major ostomy/incontinence supplier and if you leaf through those pages you'll see pictures and descriptions of just about any product you could possibly use. You wouldn't buy all that for your practice, but at least you'd know what was around. Finally, continuing education in pharmacy is an important area and providers might well want to include seminars on incontinence. Andersen: It's a big field and I don't think pharmacists are aware how big it is. Certainly the manufacturers are-like Kimberly-Clark and Procter and Gamble. It usually takes the pharmacist a while before he's aware of the available products and what the selection is. But the field is there. Most pharmacists may not be involved now, but in ten years it'll be like talking about insulin and diabetes supplies. I've been in pharmacy a few years, and I've seen that as a profession we've had to get in-
40
valved in computers, third parties, profiles, drug interactions, and nutrition. We had to educate ourselves about these. I think incontinence is in the same category, as is the whole home health care field. It's going to be part of pharmacy's responsibility. I agree with Alan that it's not so much an inventory problem as it is being knowledgeable about incontinence. It isn't an easy subjectyou don't pick it up from an ad-
'The field is there. Most pharmacists may not be involved now, but in ten years it'll be like talking about insulin and diabetes supplies.' vertisement. You have to go out and learn. If you don't want to be actively involved, at least be knowledgeable about the field. Freedman: There's no doubt it's an evolving field. I know Kimberly-Clark is going to come out with some advances in convenience, and I'm sure Procter and Gamble will come out with something competitive. At least three other companies are also gearing up right now to get into this area. It's going to be a constantly technologically evolving field with new products. Andersen: I think we already are beginning to see the field stabilize into competitive products. Pricing is becoming more of a factor-they're no longer coming out with products that are unique and expensive. Cost is being considered as an important factor. I also think the home aspect of incontinence is going to be increased substantially through new regulations and third party in-
volvement. Unfortunately, Medicare doesn't cover too much of this at present, but I think it's a real possibility for the future. This is an area that if Medicare covered now we'd be much more knowledgeable about, but I think we'll see this sort of movement in the future. Freedman: I'd like to stress again a point Alan made earlier about how this is a quality of life issue. We're seeing problems that used to be considered minor or that people didn't want to talk about now and which they no longer consider minor. Who knows how much of this psychological withdrawal has contributed to the ills of the world? We do know that urinary incontinence is the fifth leading reason people go into nursing homesand it really shouldn't be. It's obviously something we can deal with and that we are learning to deal with. The estimate of how much we are going to save the nation financially by dealing with incontinence is just astronomical. The cost of buying incontinence products is slight compared to the cost of a nursing home. Cobb:
I'd like to conclude this with the thought that we should take a broad view in regard to incontinence. The patient coming into the pharmacy with incontinence is a very complicated patient because the problem could be caused by any number of things. Even though technology is allowing us to come out with better ways to manage the problem, we can't simply have the products on hand and let it go at that. We've all agreed today that the pharmacist needs to be a resource, both by providing appropriate products and counseling on these products to the patient, and by steering patients to other appropriate health professionals, such as physicians or visiting nurses, for instance, whenever that's called for. D
American Pharmacy Vol. NS24, No.6, June 1984/360
Michael L. Freedman, MD
The
Incontinent Patient A Roundtable Discussion Roger Andersen, RPh
Alan Shubin, RPh
U
rinary incontinence is a problem many people-both patients and health professionals alike-are hesitant to discuss. Yet an estimated ten million Americans have bladder control problems, and 50% of all American women will experience some form of incontinence during their lives. The problem can drastically affect how people lead their lives. For the young, it cari lead to reclusive behavior. For the elderly, it can lead to a complete loss of independence. Incontinence, in fact, is the fifth leading cause of admissions to nursing homes. Despite the humiliation and withdrawal from society urinary incontinence can cause, it is curable in 30% of the cases and manageable in 100% of the cases. With the increasing
American Pharmacy Vol. NS24, No. 6, June 1984/351
Dorothy P. Goodman, RN
number of convenient, comfortable, absorbent products on the market, there is no need for the incontinent patient to lead less than a full, active life. The pharmacist has an important role in providing patients with the facts about incontinence and in providing appropriate products with which they can manage the prob-
lem. The pharmacist should also be aware of various drugs that can cause incontinence and be prepared to refer the patient for medical treatment when warranted. American Pharmacy invited a panel of health professionals with special knowledge about the incontinence field to share their observations with our readers. The participants were: • R. David Cobb, PharmD, moderator, president of APhA's Academy of Pharmacy Practice and associate professor at the University of Kentucky College of Pharmacy, Lexington. Cobb also works regularly in a community pharmacy serving a large population of ostomy and incontinent patients. • Michael L. Freedman, MD, director of the Division of Geriatric Medicine and the Center for Care of 31
the Elderly-Research and Education at the New York UniversityBellevue Medical Center, and professor at New York University School of Medicine. He is founder of one of the nation's first and largest comprehensive geriatric clinics at Bellevue Hospital in New York. Freedman is a consultant to many corporations and universities, including Kimberly-Clark. • Roger Andersen, RPh, director of the Home Health Care Center, Peoples Drug Stores, Washington, DC. A former owner of several community pharmacies and a pharmacy consultant for Medicare and Medicaid, Andersen has also operated a group of five home health care centers. • Dorothy P. Goodman, RN, an enterostomal therapist with the Visiting Nurse Association of Northern Virginia, Arlington, VA. Goodman has had extensive experience with elderly and incontinent patients. • Alan Shubin, RPh, owner of The Omni Pharmacy, a full service community pharmacy in Alexandria, VA, which includes ostomy and incontinent supplies as special features. Shubin is also a pharmacy consultant to the Mt. Vernon Nursing Center in Alexandria. American Pharmacy acknowledges the support of Kimberly-Clark Corporation in convening this roundtable. Cobb:
Incontinence is one of those things that's not talked about a lot, and I think many pharmacists are just now beginning to realize how large a problem it really is. It's important for us to convey to the pharmacist what the problem isfrom both a medical and a psychological standpoint-and how the pharmacist can better help this type of patient. Let's get a feel for the medical problems, and talk about how this patient differs from the one who walks in and says, "I've got a cold. What do you have for it?" Freedtnan:
Let me tell you how I got interested in the urinary incontinence
32
field. We were doing a study a few years ago on urinary tract infections in older women, and we devised a questionnaire looking for people who had urinary tract symptoms. One of the questions asked if the person was incontinent. We discovered that about 3040% of our patients were incontinent of urine and had never told us. When directly asked, they seemed to be relieved that someone had finally asked them, and it
'Taken as a medical problem, you're dealing with a condition that in about 70% of the cases has to be managed rather than treated.' turned out we had sort of opened up a can of worms in this large group of ambulatory care patients, who all of a sudden were coming to us once the word got out that we were interested in urinary incontinence. As we began to look at the literature on the problem, we found that as a medical problem, about 10% of the population over age 65 and about 30% of the population over age 80 is incontinent. This amounts to about 3 million people. But there are also about another 7 million people under the age of 65 in this country who have at least some degree of incontinence. Incontinence can be divided into five major areas by symptomatology. The first is so-called urge incontinence, where the patient constantly has to go to the bathroom. This can be caused by reversible conditions such as urinary tract infections, bladder stones, bladder tumors, urethritis, and inflan1mation of the urethra. In older people, however, it's often caused by the instability of the bladder muscle-specifically, de-
trusor muscle instability. Here it's a phenomenon of aging and in many instances is not curable. The second type of incontinence is stress incontinence. This is very, very common throughout the female population, and, in fact, 50% of all women will at one time or another experience some degree of stress incontinence. When you laugh or cough or sneeze, you lose a few drops of urine. In women, this is due to the short urethra and to multiple childbirths. In older women, it's often because the gynecologist has done a hysterectomy. It can also be caused by infection, and is sometimes seen in men with prostate problems. The third type is overflow incontinence. We see this in men when their prostates get large and there is an obstruction to the outflow of urine. The patient will constantly complain of dribbling even after they've urinated. The bladder can't empty. It can also happen in women due to bladder neck hypertrophy with age. Even though women don't have a prostate, the area where they would have had a prostate if they were men still can hypertrophy. These are usually correctable, but the older you get the less correctable it's going to be. A fourth type is reflex incontinence. We see it with spinal cord injuries where there's some kind of irritation to the spinal nerves coming to the bladder·, and it usually results in total incontinence. Then there's a fifth type commonly seen in institutions and nursing homes called functional incontinence. There's really nothing wrong with the urinary tract, but the patient just can't get to the . bathroom in time. You see this especially in a city like New York when you're dealing with some of our big institutions where there's always a great nursing and nursing aid shortage. The older patient has the side rails up and they can't get to the bathroon1, so they ring for a bedpan and there's a 15 or 20 n1inute delay. These patients aren't really
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think a lot of them just accept it because they think it's something that's supposed to happen to them because they're old. These are the people I worry about. They're old and they're scared to go out, anyway, and then they become incontinent and they're even more scared to go out. We lose track of them. I see our biggest chance for contact with them when they go into a pharmacy, or someone else goes into a pharmacy for them, and they're buying diapers, dressings, creams, and equipment like that. Somebody might be alert enough to come over and say, "Is there something I can help you with? I see you're buying a lot of ·equipment." In this way, maybe we can get these people into the stream of what's going on. Cobb:
I've got a quick question-does the word incontinence mean anything to the average person? Freedman: No, not a thing. When we were doing our questionnaire, we were very surprised to find the average person has no idea what it means. Our questions were much more direct: Do you have trouble controlling your urine or bladder? Shubin:
Freedman
incontinent if you could get them to the bathroom on time. If you take .all of these incontinent patients, we could probably cure about 20-30 % of them. So taken as a medical problem, you're dealing with a condition that in about 70 % of the cases has to be managed rather than cured. Goodman: I corne across two types of patients who are incontinent. One is the
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person who has been in the hospital for some reason and may have had some kind of surgery. They're usually elderly, and while they're in the hospital I treat them with catheters. When they come out, they're still incontinent. Luckily, most of these people are under medical care, so they're being treated and followed up on. The other type of patients are those who suddenly find them-. selves becon1ing incontinent. I
I think it's important to raise the fact that we're talking about a quality of life issue. With the elderly, it can restrict their activities to an extent where they may end up staying in the house, and not going out for fear of not being able to get to a bathroom or of wetting their clothes or creating an odor. Number one, they might not recognize the problem, and, number two, they may not know what to do about it. A lot of the senior citizens I come into contact with seem to have recurrent urinary tract infections. What typically happens is they can't get out of their apartments to actually go see a doctor because there's no transportation,
33
so they pick up· the phone and call the doctor's office, whereupon the doctor puts them on the appropriate regin1e for UTis and there will be tetnporary relief for a few days. Meanwhile, they're still sitting in their aparttnent, they're still afraid to go outside, and when they do go outside they may have an accident. Yet they're reluctant to admit to anyone that there's something wrong here. I think this is one place the pharmacist is important because the phannacist can show that he or she is accessible to issues of this sort. One thing that really struck me was that over the Christmas holidays I had a woman come into my pharmacy who was searching for a way that would allow her mother to feel like she could travel down here to visit. The reason Mom didn't want to leave the house was because she was afraid she couldn't make the car ride. What could she do? Cobb:
Incontinence is obviously a medical condition-there's nothing intentional about it. Yet there seems to be a real stigma attached to it. There's the feeling that it is a terrible thing to wet your pants out in public. Why is this? Is it because it seems so childish for a grown person to have this problem? Freedman:
We're a very cleanliness-oriented society, and probably overly so. This problem is seen as a great loss of control. It's something that is not culturally accepted. The Association of American Medical Colleges has listed the "Five I'_s" that every physician should be aware of in terms of the elderly. These are impaired homeostatis-trouble with just maintaining health; immobility-trouble with bones and joints; incompetence-Alzheimers and dementia; iatrogenic disease-trouble with drug therapy; and then, incontinence. If you look at these five major 34
Goodman
areas, patients aren't reluctant to talk to you about any of the other four. Incontinence is the only one that's really embarassing to them. I mean, no patient worries about coming in to tell you their shoulder hurts. Cobb:
I've discovered that I have no trouble with ostomy patients because there is a declared medical
condition there. They've had surgery; they've had something done to them. It seems to be all right. But it's different with incontinence. It seems a little bit like VD. It used to be unacceptable to talk about VD. At least with VD you understood that you probably did something wrong to catch it. But in this case you haven't done anything wrong and you're incontinent.
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Goodman: There's a good deal of emphasis on ostomy anymore; ostomates are a recognized population and they have groups they can go to for support and to talk about their problems. That's why most of them aren't hesitant in bringing up the subject. I don't think the incontinent population feels that way. Freedman:
the field as far as the pharmacist is concerned, being a practitioner in the private field and also in the home health field. I can remember in the '70s when ostomies and incontinence were hardly ever discussed, and it was only the specialized pharmacies that even handled the ostomy and incontinence products. Incontinence has now evolved into such a big field that I think it's running parallel with the os-
tomy products. I find ·many more people coming in and inquiring about incontinence products, even though I rarely run across someone who admits they have this particular problem. As the field has evolved, there has been a big diversification of products, and it requires qualified people who are able to explain what's available and how to use the products. In terms of pharmacy at the
A story that's germane to this discussion is how Kimberly-Clark got into this whole disposable undergarment business. Back during World War I, they got a contract to make paper wadding used in shipping guns overseas. Some of the American nurses in Europe discovered that this paper was very good for cleaning up blood in the operating room. One of the nurses then got the bright idea that it would also be good for when you would menstruate. At that point in the history of the world, there had never been anything devised for menstruation, and most women would just stay home-they'd be sick for one week every month. When this nurse came back to Wisconsin, she told somebody about the paper, and Kimberly-Clark got the wonderful idea to 1nanufacture Kotex. What they did, essentially, was to take a medical condition-because you were home one week a month while you were a young woman-and turn it into a nonmedical condition. The point is that we could do something like this with urinary incontinence. Most of the time, it doesn't have to impair our daily life. The key to it is patient education, and to make people realize that of all the problems you can get as you go through life, incontinence is one of the minor ones. We may have trouble curing it, but we really don't have any trouble managing it. Andersen:
I can give you a quick feeling for
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Andersen
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community level, you have to have a training program for the person who's going to handle the problem. You can't just put it on a self-service basis. Even though there are some products that are doing national advertising, they represent just a limited part of the incontinence field. Freedman: 1 was at a party recently with two
friends of mine. One is a pharmacist and one is a doctor practicing in my home town. The two of them were talking about incontinence and the pharmacist said, "There's an unbelievable number of people coming into the pharmacy complaining of incontinence," and the doctor practicing in the same area said, "Really? I don't see any patients at all for that." I think this paints out that people are looking to the pharmacist for help because he or she is less threatening than the physician. A problem I see is that as national advertising for incontinent products picks up, the emphasis on selling the product may make it more difficult to find the 30% of patients who are curable. The pharmacist should understand that he's an important resource and should encourage his patients to undergo a thorough workup at least somewhere in the course of the illness so we don't miss that 30%.
Shubin: I couldn't agree with you more. I think the issue as far as the pharmacist is concerned is the pharmacist's accessibility and willingness to make himself or herself available to the patient to discuss these issues. I agree completely with Roger when he says you need a training program. If a large chain decides to make these products available, they should give some guidance to the pharmacist, and even give some guidance to the clerks, to make them aware that because there is a patient population who may be reluctant to talk about this,
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'You have to have a training program for the person who's going to handle the problem. You can't just put it on a selfservice basis.' pharmacists should make themselves available. The key issue is accessibility. It's easier to be accessible in my practice setting, simply because it's small and intimate. But I don't think we should, or have to, relieve the chains of this responsibility. Freedman: The patient we're all missing is the young woman who has some amount of stress incontinence. She's going in and buying panty liners or menstrual pads for this, and we're not giving her any kind of education or treatment that could prevent further problems. Andersen: An interesting fact about this field is that in the years I've been running ads for various home health products, the responses for incontinent products have far exceeded those for any other item, whether it's diabetic or something else. We've run ads on new types of incontinent underpads, and not just strictly on price but on the fact that they're available, and our response generally runs higher than on all other categories. I think the reason is that there are a lot of people who see the ad and say, "I fit into that category. Here's somebody that knows about it." It proves to me that there are a lot more people interested in incontinent products than in durable medical equipment or some of the other programs we've had. Cobb:
We all seem to agree that the
pharmacist is the most available health professional and it's logical that we're the people to do a lot of this work with the incontinent. Yet I don't think most pharmacists know how to proceed. How do you start in this field? Andersen: We've done a survey in the Washington DC area and we've found very little distribution of incontinent products in either chains or independent pharmacies. You find one, two, or three products, and that's the maximum. In fact, I'd say that over 50% of the stores don't have three incontinent products. They take on one or two of the national products that are on a self-service basis. I think pharmacists are aware of the products, but it seems to be a matter of inventory and time. It generally takes a good five or ten minutes for a consultation with an incontinent patient, to let them know what's available and so forth, and can sometimes take as long as half an hour. Also, there is such a variety of items available that the community pharmacist faces an inventory problem, in terms- of initial stocking, continuous flow of inventory, what's available, and so on. It's interesting to compare this with the diabetic field. There are about 10 million diabetics in the U.S. and there are at least 10 million incontinent patients .in the U.S. Most of the pharmacies have an involvement in diabetes-insulin and so forth-and are knowledgeable about the problem, while few pharmacies are really into the incontinent field. Yet if anyone ever made an indepth study on it, I'm quite sure they'd find that the monetary aspect of incontinent patients is the same, if not more, than with the diabetic patient. ·The problem i that it's not as easy a field to get into. There's more of a monetary outlay in getting involved. There's more involvement in term of inventory and training. You ha e to have literature a ail ble.
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While I agree the pharmacist is the logical person to come to with the first questions about incontinence, I don't think you're going to find a large number of pharmacies approaching it as one of their main features. Not that it shouldn't be, but that's how it is. Goodman: I don't think you really need a big inventory to start. The important part is to have patients come into the pharmacy with their questions and to have their questions answered. The commercial says, "Ask your pharmacist." I think that's great. By asking the questions, these people can be steered back into the system. It's not necessary to have all the supplies right there. As a matter of fact, I really don't like to see a lot of ostomy and incontinent supplies out on anybody' s shelves because I don't want to see people just going in and buying these things. We run the risk of the patient not having the condition
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properly diagnosed. Freedman: There's been some talk today of self-catheterization and that's something that shouldn't be forgotten. It's a very important technique, especially in younger people. You have almost no infection rate with intermittent self-catheterization, and people can learn to do it-they don't mind learning to do it. The pharmacist can suggest this as an option, or at least suggest that the patient take it up with his physician. The pharmacist should also keep in mind that a number of medications can contribute to urinary incontinence-especially a lot of the things that are bought over the counter, like anticollagenase products and the antihistamines people are buying like crazy. There are many scenarios with a lot of these ore medications, and it's the role of the pharmacist to warn people, especially the elderly, about these
side effects. And if one week the pharmacist sees somebody buying benadryl to sleep and two weeks later the patient is coming in to buy incontinent pads, the pharmacist should make the connection. There are a lot of simple things to watch out for that people often don't consider. Many women are now taking calcium supplements for osteoporosis, and it's probably a good idea. But you've also got to remember that hypercalcemia can lead to diuresis and that can be a reason somebody becomes incontinent. Cobb: That's a good point. Now, I have no problem in saying to a patient that this may color your urine red. But how do you tell them this may cause them to wet their pants? Suddenly I get very uncomfortable because I don't deal with this on a daily basis. How do you handle that? What's the correct approach? 37
person comes up with a question. To me, it boils down to establishing the notion and the image that the pharmacist is (1) an acces-sible person, and (2) the appropriate person to ask about OTC products. We've come a long way in getting pharmacists to understand that their job is not simply to count pills, type labels, and say, "Thank you. That's $5.95." We want the notion that pharmacists are drug information providers to become pervasive. As the public comes to understand that, things will be better. Cobb: How does the pharmacist who understands very little about incontinence get started? What's the minimum in terms of products you have to stock?
Shubin
Shubin: I'm not sure I know the answer. One of the li.mitations we all have with a person walking into the pharmacy is that we don't know their medical history until they tell us about it. To be perfectly honest, most times when I sell OTC products I don't say anything unless it's an obvious situation, such as when someone has hypertension and is buying a decongestant. I don't 38
know how you overcome this unless people go to the same pharmacy all the time and establish a relationship with the pharmacist, and I'm not sure that's always the case. The self-service aspects of a lot of pharmacies is a disadvantage here. Most people who walk into a pharmacy to buy whatever OTC thing they want don't get within 40 yards of a pharmacist. The only way the pharmacist is going to interact with that person is if the
Shubin: I agree with what Dot said earlier about it not being necessary to immediately stock each and every incontinent product that is on the market. Roger's point is well taken, too, that inventory costs can be a real problem for a community pharmacist. That's definitely an issue. But I don't think it's necessary to stock every product. In my store, I carry one of the disposable products; I carry another line of more elaborate incontinent pant; I carry some condom catheters; and I have some leg bags, some extension tubing, and a couple of Foley catheters-but I don't use them on the ambulatory patient, obviously. For the rest, most pharmacists have the advantage of 24-hour delivery service from their wholesaler. Should they need something, they can always get it the next day. Many pharmacists also have interrelationships with other drug stores in the area should they need something quickly. So I think the minimum one needs to carry is a good, convenient disposable product, perhaps a more elaborate set of incontinent pants with a liner, and then when
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you get into the area of condom catheters and leg bags, I think you can play that by ear. You'll want to see the kinds of people who are coming into your store for these and the kinds of particular problems you're going to be faced with. The first part of your question is more difficult to answer. If you want to get involved in this area but have no knowledge: what do you do? I'd like to be able to say we came out of school with some basic knowledge about subjects like incontinence, but that's not the case for the most part. People like Dot are probably the best resource around, and are underutilized by pharmacists. Most pharmacists don't even know what ETs are, especially if they don't deal with ostomates. Another thing to do is identify the companies that provide these products and write to them for information. There's a wealth of information available from them. A simple way to get an overview is to pick up a catalog of any major ostomy/incontinence supplier and if you leaf through those pages you'll see pictures and descriptions of just about any product you could possibly use. You wouldn't buy all that for your practice, but at least you'd know what was around. Finally, continuing education in pharmacy is an important area and providers might well want to include seminars on incontinence. Andersen: It's a big field and I don't think pharmacists are aware how big it is. Certainly the manufacturers are-like Kimberly-Clark and Procter and Gamble. It usually takes the pharmacist a while before he's aware of the available products and what the selection is. But the field is there. Most pharmacists may not be involved now, but in ten years it'll be like talking about insulin and diabetes supplies. I've been in pharmacy a few years, and I've seen that as a profession we've had to get in-
40
valved in computers, third parties, profiles, drug interactions, and nutrition. We had to educate ourselves about these. I think incontinence is in the same category, as is the whole home health care field. It's going to be part of pharmacy's responsibility. I agree with Alan that it's not so much an inventory problem as it is being knowledgeable about incontinence. It isn't an easy subjectyou don't pick it up from an ad-
'The field is there. Most pharmacists may not be involved now, but in ten years it'll be like talking about insulin and diabetes supplies.' vertisement. You have to go out and learn. If you don't want to be actively involved, at least be knowledgeable about the field. Freedman: There's no doubt it's an evolving field. I know Kimberly-Clark is going to come out with some advances in convenience, and I'm sure Procter and Gamble will come out with something competitive. At least three other companies are also gearing up right now to get into this area. It's going to be a constantly technologically evolving field with new products. Andersen: I think we already are beginning to see the field stabilize into competitive products. Pricing is becoming more of a factor-they're no longer coming out with products that are unique and expensive. Cost is being considered as an important factor. I also think the home aspect of incontinence is going to be increased substantially through new regulations and third party in-
volvement. Unfortunately, Medicare doesn't cover too much of this at present, but I think it's a real possibility for the future. This is an area that if Medicare covered now we'd be much more knowledgeable about, but I think we'll see this sort of movement in the future. Freedman: I'd like to stress again a point Alan made earlier about how this is a quality of life issue. We're seeing problems that used to be considered minor or that people didn't want to talk about now and which they no longer consider minor. Who knows how much of this psychological withdrawal has contributed to the ills of the world? We do know that urinary incontinence is the fifth leading reason people go into nursing homesand it really shouldn't be. It's obviously something we can deal with and that we are learning to deal with. The estimate of how much we are going to save the nation financially by dealing with incontinence is just astronomical. The cost of buying incontinence products is slight compared to the cost of a nursing home. Cobb:
I'd like to conclude this with the thought that we should take a broad view in regard to incontinence. The patient coming into the pharmacy with incontinence is a very complicated patient because the problem could be caused by any number of things. Even though technology is allowing us to come out with better ways to manage the problem, we can't simply have the products on hand and let it go at that. We've all agreed today that the pharmacist needs to be a resource, both by providing appropriate products and counseling on these products to the patient, and by steering patients to other appropriate health professionals, such as physicians or visiting nurses, for instance, whenever that's called for. D
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