Urinary Incontinence: A Neglected Geriatric Syndrome in Nursing Facilities

ORIGINAL STUDIES

Urinary Incontinence: A Neglected Geriatric Syndrome in Nursing Facilities Larry W. Lawhorne, MD, Joseph G. Ouslander, MD, Patricia A. Parmelee, PhD, Barbara Resnick, PhD, CRNP, FAAN, FAANP, and Barbara Calabrese, RN, BA Purpose: Urinary incontinence (UI) is common but inadequately assessed and treated in nursing facility (NF) residents. The purpose of this study is two-fold: (1) to determine perceptions about the importance of UI and its management in the NF setting compared with other geriatric syndromes and (2) to compare barriers to UI care as perceived by physicians, geriatric nurse practitioners (GNPs), directors of nursing and other nurses in administrative positions (DONs), and nursing assistants (NAs). Methods: Computer-based surveys of physicians and DONs and a hard copy survey of NAs at their national meetings; an online survey of GNPs. Results: Responses included 395 physicians (31% response rate), 152 DONs (34%), 118 GNPs (23%), and 277 NAs (60%). Physicians, GNPs, and DONs evaluated and managed UI significantly less often than 5 other geriatric syndromes (behavioral symptoms of dementia, falls, unintended weight loss, pain, and delirium). In contrast, NAs were more likely to be involved in UI care than in care provided for residents with any of the other 5 syndromes. All 4 groups agreed that UI has less effect on clinical outcomes than the other 5 syndromes. However, DONs rated UI first with respect to cost of care; NAs third behind falls and pain; and physicians and GNPs rated UI fourth behind falls, behavioral symptoms, and

delirium. With respect to quality of life effects, physicians and GNPs rated UI fifth and fourth respectively and DONs fourth. In contrast, NAs rated UI second only to pain with respect to its effect on quality of life. Perceived barriers differ among the 4 groups with physicians relatively more concerned that drug treatment alone is ineffective (P ⫽ .002); GNPs relatively more concerned with lack of effective nondrug interventions (P ⫽ .001); and DONs relatively more concerned about sufficient time to assess and manage UI (P ⫽ .001). NA respondents rated concern about anticholinergic drug effects lower than did respondents in the other 3 groups (P ⫽ .001). Conclusion: Physicians, GNPs, and DONs are more likely to be involved in evaluating and managing behavioral symptoms of dementia, pain, falls, delirium, and unintended weight loss than UI in the NF setting. This leaves NAs as first-line managers for a condition that they perceive to have an important impact on quality of life. Perceived barriers to improving UI care differ among the 4 groups suggesting that approaches to overcoming the barriers should be multi-faceted. (J Am Med Dir Assoc 2008; 9: 29–35) Keywords: Urinary incontinence; geriatric syndromes; nursing facilities

Urinary incontinence (UI) with or without symptoms of overactive bladder is a common condition that may adversely affect physical and psychosocial functioning as well as quality of life for many older adults across all settings of care.1–5 The

association between UI and depression appears particularly strong.6 –9 In addition, evidence is emerging that the relationship between UI and sleep disturbance may be more complex than originally thought.10,11 On the other hand, UI may not

Department of Geriatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH (L.W.L.); Division of Geriatric Medicine and Gerontology, Department of Medicine, Center for Health and Aging, Emory University School of Medicine and the Birmingham/Atlanta VA GRECC, Atlanta, GA (J.G.O.); Department of Psychiatry and Behavioral Science, Emory University School of Medicine and Birmingham/Atlanta VA GRECC, Atlanta, GA (P.A.P.); University of Maryland School of Nursing, Baltimore, MD (B.R.); American Medical Directors Association Foundation, Columbia, MD (B.C.).

Baum (Canton, OH), J. Kenneth Brubaker (Mt. Joy, PA), Colene Byrne (Albany, NY), Khaled Imam (Royal Oak, MI), Kristijan Kahler (Novartis, East Hanover, NJ), Linda Keilman (East Lansing, MI), Betsy Kemeny (Grove City, PA), Janet Lieto (Cherry Hill, NJ), June McKoy (Chicago, IL), and Douglas Scharre (Columbus, OH).

The authors acknowledge members of the AMDA Foundation Research Network and in particular members of the work group on urinary incontinence: Elizabeth

ORIGINAL STUDIES

Address correspondence to Larry W. Lawhorne, MD, Department of Geriatrics, Boonshoft School of Medicine, Wright State University, 627 Edwin C. Moses Boulevard, Fifth Floor, East Medical Plaza, Dayton, OH 45408. E-mail: [email protected]

Copyright ©2008 American Medical Directors Association DOI: 10.1016/j.jamda.2007.08.003 Lawhorne et al 29

be a strong independent predictor for pressure ulcers, frailty, mortality, or nursing facility placement.12–17 Nevertheless, UI is prevalent in the nursing facility setting and is correlated with poor resident health status and high resource utilization.18 In addition, prevalent and new or worsening UI decrease quality of life even in frail, functionally and cognitively impaired nursing facility residents.19 According to publicly available quality measures generated from 2006 Minimum Data Set (MDS) assessments, 48% of the people residing in US nursing facilities had urinary or fecal incontinence.20 This prevalence is similar to findings of a 1990 study of 2014 nursing home residents in 270 facilities in 10 states in which 49% had UI,21 but less than the prevalence of 65% found in a retrospective cohort study of over 130 000 residents using an MDS database.19 The predominant intervention for residents with urinary incontinence is the use of briefs or pads (84%), toileting programs (39%), indwelling catheters (3.5%), and external catheters (1.2%).21 However, a study of 347 residents in 14 southern California nursing facilities in 2000 and 2001 found that despite strong evidence that toileting programs are effective, most incontinent residents were not receiving the scheduled interventions documented in the care plan.22 Reasons for the less than optimal approach to this geriatric syndrome are probably multifactorial but may include inadequate knowledge and skills about UI in general, inability to implement specific guidelines for UI care in the nursing facility, insufficient staffing, and poor communication among health care professionals and paraprofessionals.23–27 However, UI also may be overshadowed by issues that seem more important to the health care teams that evaluate and treat nursing facility residents. Medical and neuropsychiatric conditions (eg, congestive heart failure, diabetes mellitus, dementia) and geriatric syndromes other than UI (eg, falls, weight loss, delirium) may consume so much time and effort that UI becomes the neglected geriatric syndrome. While this hypothesis has face validity, there is little in the literature to support it. Therefore, the purpose of this study is to determine perceptions of diverse nursing facility health care team members about the importance of UI and its management compared with other geriatric syndromes. In addition, we compare barriers to UI care as perceived by the 4 groups of team members: physicians, geriatric nurse practitioners (GNPs), directors of nursing (DONs), and nursing assistants (NAs). METHODS This study was conducted by the American Medical Directors Association (AMDA) Foundation Long-Term Care Practice-Based Research Network. The Network, patterned after the primary care practice-based research networks, was established as the research arm of the Foundation in 2000 with the overall mission of enhancing grass roots research in nursing facilities.28 Part of the Network’s mission is to determine the value of the AMDA clinical practice guidelines. In service of that goal, this project was generated to describe health care workers’ perspectives on UI and to establish a foundation for additional study on UI guideline implementation.29 Network research projects such as the one described here 30 Lawhorne et al

start with a question that is generated by one or more Network members. Once the question is determined by the Network Steering Committee to be important and likely to be funded, a work group refines the research question, develops methodology, submits Institutional Review Board (IRB) applications, and implements the study following IRB approval. At the time of this study, the Network comprised approximately 300 members across the country. The UI work group first convened at the Network’s Fourth Annual Meeting in Chicago, Illinois, in October 2004. Deliberations began with a critique of 2 questions: Why is UI such a problem in the NF setting? Why are the AMDA guidelines not used more broadly and effectively? As discussions continued over the course of the 2-day meeting, the work group hypothesized that physicians are not often asked to be involved in the assessment and management of UI but rather are directed more often by the nursing staff to help in assessment and management of specific medical and neuropsychiatric conditions or other geriatric syndromes such as delirium or falls. Furthermore, physicians, nurse practitioners, nurses, and nursing assistants may perceive UI differently based on how often and to what extent each is involved in its recognition, assessment, and management. To test this hypothesis, the work group developed a set of survey instruments to be administered to long-term care physicians (computer-based at the 2005 AMDA Annual Symposium), members of the National Conference of Gerontological Nurse Practitioners (NCGNP; online from September 9–26, 2005), long-term care directors of nursing (computer-based at the 2005 Annual Meeting of the National Association of Directors of Nursing Administration/Long-Term Care [NADONA]), and nursing assistants (pen and paper at the 2005 Annual Meeting of the National Association of Geriatric Nursing Assistants [NAGNA]). Each of the 4 survey instruments had the same basic 3-part format. Part 1 consisted of statements about 4 domains of care (involvement in evaluation and management, clinical outcomes, cost of care, and quality of life) for 6 geriatric syndromes: UI, delirium, pain, falls, behavioral disturbances related to dementia, and unintended weight loss. For each of the 4 domains, respondents ranked in order of importance the 6 syndromes (eg, how frequently they are involved in evaluation and management; effect of the syndrome on quality of life). Part 2 consisted of Likert scale responses to statements about potential barriers to improving management of UI. The potential barriers were developed by the authors and members of the Research Network’s UI work group by using a consensus approach based on existing literature as well as experiences of the members of the UI work group and the authors. Each group of respondents (physicians, GNPs, DONs, and NAs) rated various barriers pertinent to their professions, 11 of which were rated by all 4 respondent groups. Part 3 comprised questions about the survey respondent and the facility in which the respondent worked or attended residents. Statistical analyses of data proceeded in 3 phases. First, characteristics of the samples and the facilities in which respondents worked (Part 3) were examined using descriptive statistics. Two sets of primary analyses were then conducted. First, group differences in ranks assigned to the 6 syndromes in each of the 4 JAMDA – January 2008

Table 1. Comparison of Selected Characteristics of Respondent Facilities

NF ownership* For profit NFP Number of beds ⬍ 50 50–99 100–149 150–199 200 or more Location Urban Suburban Rural Access to ultra-sound bladder scanner Frequency of PITs Pressure ulcer Falls Behavior Weight loss Pain Incontinence

Physician

DON

Nurse Practitioner

Nursing Assistant

55% 34%

56% 38%

51% 39%

53% 36%

4% 20% 39% 19% 19%

6% 27% 34% 12% 21%

4% 18% 42% 22% 15%

3% 31% 32% 20% 14%

46% 33% 21% 71%

40% 20% 40% 13%

51% 36% 13% 23%

21% 17% 62% 17%

74% 68% 66% 54% 35% 22%

81% 88% 45% 77% 50% 26%

68% 62% 31% 38% 25% 16%

70% 74% 64% 77% 60% 57%

DON, Director of nursing; NFP, not-for-profit; PITs, Process Improvement Teams. * The remainder of the facilities ⫽ government-owned, hospital-based, or other.

domains were examined using repeated measures multivariate analysis of variance (MANOVA). Then, between-subjects MANOVAs explored group differences in ratings of 11 barriers to good continence care. For both sets of primary analyses, appropriate post hoc tests were used to describe patterns of findings in detail. The study was funded by a grant from Novartis Pharmaceuticals Corporation (East Hanover, NJ). The protocol and survey instruments were approved by the University Committee Involving Research on Human Subjects at Michigan State University, which serves as the designated IRB for the AMDA Foundation’s Federalwide Assurance through the US Department of Health and Human Services Office of Human Research Protection. For all 4 surveys, the advertised incentive for participating was the option to enter a drawing for one of several prizes worth approximately $200 each. RESULTS Response Rates Responses to the surveys were as follows: 395 physicians (32% of all registrants at the 2005 Annual AMDA Symposium); 118 geriatric nurse practitioners online (23% of total NCGNP membership); 152 nurses (34% of registrants at the 2005 NADONA annual meeting); and 277 nursing assistants (60% of NAGNA conference attendees). Sample Characteristics Physicians Almost half of physician respondents are internists and a little over one third are family physicians. Ninety percent are board certified, and half of this group reported holding a ORIGINAL STUDIES

Certificate of Added Qualification in Geriatric Medicine. A little more than 50% of the physician respondents report having CMD status through the American Medical Directors Association’s certification process. Twenty percent serve as medical director only, while almost half combine medical direction and attending physician duties. Remaining respondents serve as attending physicians only. The largest proportion of respondents (39%) work in facilities with 100 to 149 beds, but almost 1 in 5 physicians based survey responses on their experiences in facilities with more than 200 beds (Table 1). Fifty-five percent of respondents work in for-profit facilities. Facilities in which physician respondents work are predominantly urban (46%) while 33% are located in suburban areas and 21% in rural settings. Seventy-one percent of physician respondents report having access to a bladder scanner. While a majority of respondents report having process improvement teams to address quality concerns about pressure ulcers (74%), falls (68%), behavioral disturbances (66%), and weight loss (54%), only a minority (22%) report having a process improvement team to address incontinence. Process improvement team activity for pain is also less common (35%) than for pressure ulcers, falls, behavioral disturbances, and weight loss. Directors of Nursing Essentially all of the respondents at the annual meeting of the National Association of Directors of Nursing Administration are registered nurses with slightly over one quarter having a Master’s degree. Almost 80% of this group serves as a facility’s director of nursing (DON); the remaining 20% hold titles such as assistant director of nursing, infection control nurse, or quality assurance coordinator. Most work in forLawhorne et al 31

Table 2. Comparison of the 4 Groups’ Rank Ordering of 6 Geriatric Syndromes, Rank (mean) Physician

GNP

DON

NA

1(2.03)a 4(3.78)a 3(3.05)a 2(2.97)a 5(3.83)a 6(5.13)a

1(1.80)a 4(3.73)a 3(3.36)ab 2(3.11)ab 5(3.95)a 6(5.05)ab

2(2.49)b 5(4.48)b 1(1.78)c 3(3.46)b 4(4.23)ab 6(4.60)b

2(2.71)b 5(4.59)b 4(3.72)b 3(3.26)ab 6(4.66)b 1(2.00)c

2(2.87) 3(3.52)a 4(3.57)a 1(1.74)a 6(5.30)a 5(3.69)a

2(2.57) 3(3.57)a 5(3.77)a 1(1.97)a 6(5.38)a 4(3.75)a

3(3.10) 5(4.51)b 2(2.89)b 1(2.04)a 6(5.00)ab 4(3.46)a

3(2.79) 5(4.21)b 4(3.63)a 1(2.62)b 6(4.86)b 2(2.75)b

2(2.64) 3(3.28)a 1(2.53) 5(4.23)a 6(4.56) 4(3.53)a

2(2.89) 3(3.19)a 1(2.50) 5(4.38)ac 6(4.72) 4(3.33)a

5(4.24) 6(4.81)b 2(2.30) 4(3.68)b 3(3.76) 1(2.16)b

4(3.42) 6(4.40)b 1(2.88) 2(2.91)bc 5(4.22) 3(3.11)b

5(3.70)a 2(2.54)a 1(2.41) 4(3.65)a 3(3.34)a 6(5.09)a

5(3.63)ac 2(2.91)a 1(2.44) 4(3.43)a 3(3.26)a 6(5.33)a

3(3.76)b 5(3.99)b 1(2.32) 2(2.71)a 4(3.80)b 6(4.44)b

3(3.48)ac 5(4.18)b 1(2.51) 2(3.07)b 4(3.57)ab 6(4.26)a

a

Evaluation / management Behavioral symptoms Delirium Falls Pain Weight loss Incontinence Quality of lifeb Behavioral symptoms Delirium Falls Pain Weight loss Incontinence Cost of carec Behavioral symptoms Delirium Falls Pain Weight loss Incontinence Clinical outcomesd Behavioral symptoms Delirium Falls Pain Weight loss Incontinence

Note: Within rows, means with different letters are significantly different from each other at P ⬍ .001 (Games-Howell statistic). GNP, Geriatric nurse practitioner; DON, director of nursing; NA, nursing assistant.

profit facilities located in nonurban areas (Table 1). As with physician respondents, DONs report that incontinence process improvement teams are less prevalent (26%) than teams established to address other syndromes (falls team, 88%; pressure ulcer team, 81%; weight loss team, 77%). About half of the nurse administrator respondents have a pain team, and slightly fewer than half have a team to evaluate quality concerns related to behavioral disturbances. In contrast to the 71% of physicians who report having access to a bladder scanner, only 12.5% of DON respondents report bladder scanner availability in their facilities. Geriatric Nurse Practitioners Just over 80% of the nurse practitioners responding to the online survey classified their role in the NF as advance practice nurses, with the remaining respondents working in administration, education, or other activities not further described. A majority of GNP respondents report having active pressure ulcer and falls teams (68% and 62% respectively) but only 16% indicate that their facilities have a process improvement team for incontinence (Table 1). Twenty-three percent of GNP respondents report having access to a bladder scanner. Nursing Assistants Among the 277 nursing assistants responding to the pen and paper survey, 43% had received a high school diploma or GED, 38% had some college courses, and 13% held an Associate’s or 32 Lawhorne et al

Bachelor’s degree. Seventeen percent of NA respondents report having access to a bladder scanner; in contrast to the other groups, 57% of NAs report having a urinary incontinence team in the facility in which they work. Table 1 summarizes the 4 groups with respect to some selected facility characteristics. While there is little variation across the 4 groups with respect to NF ownership and bed size, there are potentially important differences in other areas. For example, rural facilities are more heavily represented among the DON and nursing assistant respondents while the physician respondents report much greater access to an ultrasound bladder scanner. The latter finding may have to do with the wording of the item about bladder scanner accessibility. Physicians may have responded in the affirmative if they had access to a scanner at any site in which they practiced. In addition, NAs report working in facilities that have a much higher prevalence of process improvement teams addressing urinary incontinence. This observation may be related to selection bias in that facilities more involved in quality care initiatives may have encouraged and financially supported their NAs to attend the national meeting at which this survey was conducted. Syndrome Ranks in 4 Domains of Care Table 2 summarizes responses from the 4 groups about the relative importance of 6 common geriatric syndromes. Each of the 4 respondent groups (physicians, GNPs, DONs, and NAs) ranked in order of importance each of 6 geriatric syndromes JAMDA – January 2008

Table 3. Comparison of Relative Importance of Barriers (1 ⫽ not a barrier to 5 ⫽ significant barrier) Potential Barrier Lack of information Lack of effective non-drug intervention Drug treatment alone ineffective Anticholinergic effects of drugs Cognitive side effects of drugs Cardiac side effects of drugs Concern about 9 or more meds QI Drug costs Inability to assess treatment response Cumulative anti-cholinergic effect Insufficient time to assess and manage

Physician ab

2.98 3.27a 3.01 3.62a 3.60a 2.74 2.74 2.92 2.96a 3.31a 3.02a

GNP ab

2.84 3.77b 2.75 3.37ab 3.52a .92 2.72 2.71 3.07a 3.26ab 3.28a

DON a

3.10 3.25ac 2.84 3.01b 3.01b 2.80 2.60 2.54 2.84ab 2.79b 3.46b

NA b

2.75 2.85c 2.67 1.97c 2.76b 2.76 2.48 2.88 .51b 3.15b .93a

F

P

3.65 17.87 5.07 119.31 48.00 ⬍1 2.35 4.16 9.65 8.71 7.99

.012 .001 .002 .001 .001 ns ns .006 .001 .001 .001

Note: Within rows, means with different letters are significantly different from each other at P ⬍ .001 (Games-Howell statistic). GNP, Geriatric nurse practitioner; DON, director of nursing; NA, nursing assistant; ns, not significant; QI, Quality Indicator.

(behavioral symptoms of dementia, delirium, falls, pain, weight loss, and incontinence) in 4 domains: the frequency with which the respondent was asked to assist with evaluation or management and the impact of each syndrome on quality of life, clinical outcomes, and cost of care. To assess whether the 4 respondent groups differed in their rank ordering of the 6 syndromes, we first conducted a repeated measures multivariate analysis of variance (MANOVA) for between subjects effects of group (physicians, GNPs, DONs, NAs) in each of the 4 domains rated (evaluation and management, quality of life, clinical outcomes, and cost of care). “Syndrome” formed the within subjects variable. Because each group was using the same rating scale (rank orders from 1 to 6) for each syndrome, no overall effect of group was expected. However, we did expect to see an overall main effect for syndrome, based on our hypothesis that incontinence may be perceived as being less important than others being rated. We further hypothesized that this lesser perceived importance of incontinence compared with other geriatric syndromes would differ across respondent groups, with those having most direct contact with the residents (NAs and, to a lesser extent, DONs) ranking it as more important than physicians and geriatric nurse practitioners. As expected, the repeated measures MANOVA yielded no overall main effect for the between subjects group factor, F (12, 2064) ⫽ 1.52, nonsignificant. In contrast, the within subjects syndrome variable showed a highly significant effect, Wilks’ lambda ⫽ 0.197, F (20, 764) ⫽ 155.40, P ⬍ .001. Also as hypothesized, a significant group by syndrome interaction, lambda ⫽ 0.264, F (60, 2280.2) ⫽ 21.38, P ⬍ .001, indicated that different groups of nursing facility providers ranked the syndromes differently across the domains. The 4 groups’ average rank orders of each syndrome in the 4 domains and the overall rank of each syndrome within each group (Table 2) demonstrate reliable patterns of differences among the groups. Post hoc tests of significance (Games-Howell statistic) verified these patterns of differences. The NAs indicated that they are most frequently asked to assist with evaluation and management of urinary incontinence, followed by behavioral symptoms and pain. In contrast, the other 3 groups ranked incontinence lowest on the evaluation and management domain. Overall, GNP ratings strongly resemORIGINAL STUDIES

bled those of physicians, and DONs were generally intermediate between physicians/GNPs and NAs. All groups ranked pain as having the strongest effect on quality of life. However, NAs again differed from other groups in their views on incontinence, ranking it second to pain, while DONs and GNPs ranked incontinence fourth and physicians, fifth. All 4 groups agreed that incontinence has the least effect on clinical outcomes while falls have the greatest effect. All groups except DONs, who rated it second after incontinence, ranked falls as most costly of the syndromes. Table 3 describes responses to 11 statements about perceived barriers to providing quality incontinence care in the nursing facility setting. The overall multivariate effect for group was highly significant, Wilks’ lambda ⫽ 0.543, F (33, 2407.74 ⫽ 15.30, P ⬍ .001. Univariate F statistics revealed that 9 of the 11 barriers contributed to the overall effect. Physicians and, to a lesser extent, GNPs tended to focus on medication effects. Both side effects and cost of medications for treating urinary incontinence were rated significantly higher than by other groups, and generally higher than other barriers. Nurse practitioners also cited the lack of effective nondrug interventions. DONs perceived that lack of time and information were the greatest barriers, and agreed with GNPs that failure to carry out nonpharmacologic treatments is an important barrier to continence care. For 7 of the 9 barriers, NAs rated the barriers lower than did other groups; they were especially less concerned about anticholinergic drug effects. Less concern in this area for NAs is understandable since they may not be as aware of the resident’s drug regimen as the other 3 groups. DISCUSSION There are 4 major findings regarding perceptions about these common geriatric syndromes in the nursing facility setting. First, results of this study confirm the hypothesis that physicians and geriatric nurse practitioners are less involved in the evaluation and management of urinary incontinence than with delirium, falls, pain, weight loss, or behavioral symptoms of dementia. Nursing assistants, on the other hand, report that their involvement with UI outranks that of all of the other syndromes. Second, while physicians, GNPs, and DONs rated UI as fourth or fifth with respect to effect on quality of life, nursing assistants Lawhorne et al 33

rated UI second only to pain. Third, DONs, who probably have the best grasp of a facility’s budget, judged UI as having the greatest effect on cost of care. And finally, all 4 groups rated UI last with regard to impact on clinical outcomes. Perceived barriers to improving incontinence care also differ by group. Physicians see the greatest barriers as potential adverse drug effects and the observation that drug therapy alone is ineffective. GNPs rate inadequate implementation of nondrug interventions as the most important barrier. DONs see insufficient time to conduct assessments and interventions as the primary barrier. When compared with the other 5 geriatric syndromes in this study, the finding that UI ranks low on the list for physicians and GNPs is not surprising. However, UI is perceived to be an important problem by those who have it. For example, in a Montreal study of 1000 older women’s health priorities and perceptions of care, treating urinary incontinence was identified as a health care delivery deficiency along with addressing memory loss and preserving mobility and function.30 The basis for patients’ placing UI on a more equal footing with other conditions is found in studies that suggest that UI is independently associated with loneliness,1 is associated with lower sleep scores (especially for patients with overactive bladder),2 and has a significant effect on social well-being and productivity both at home and at work.3 Two recent reports emphasize the pervasiveness of UI and its impact on quality of life. A cross-national study involving treatment-seeking women in 14 European countries reports that in most countries, more than 60% of women with UI are either moderately or severely bothered by their symptoms.4 In a study of Medicare beneficiaries enrolled in managed care, elderly patients with incontinence were found to be more depressed and to have worse perceived health than those without urinary incontinence, with the negative impact of UI on certain domains of quality of life surpassing that of other severe comorbidities.5 Perhaps the findings from studies such as these explain why nursing assistants, the members of the care team closest to the nursing facility resident, rank UI as being such an important factor in quality of life in the present study. While at least one study reports that medical directors view incontinence as a nursing problem,31 the link between depression and urinary incontinence6 –9 should give physicians and GNPs reason to address incontinence more aggressively. Overactive bladder symptoms and urinary incontinence may in fact contribute to some of the behavioral symptoms and mood changes that consume so much evaluation and management time, especially for residents who have dementia or other neuropsychiatric conditions that impair effective communication. Physician concern about drug side effects as a barrier to improving incontinence care is also not surprising. An analysis of MDS data on 29 645 nursing facility residents revealed that only 8.7% of residents with severe UI were receiving drug treatment for it.18 The mechanism of action of pharmacological agents used to treat overactive bladder is to block acetylcholine at the muscarinic receptors of the bladder to decrease the frequency and intensity of involuntary detrusor contractions. However, available antimuscarinic agents do not target the bladder specifically, and physicians appear to be increasingly concerned 34 Lawhorne et al

about their potential effects on cognitive function in older adults.32 Both physicians and GNPs in our surveys are concerned that nondrug interventions are not being effectively and consistently implemented, a concern supported by existing literature. For example, a study of 270 nursing facilities in 10 states revealed that guidelines for assessment and management were not being followed,21 while authors of a smaller study in southern California concluded that even when potentially effective nondrug interventions were documented in the care plan, they were not being done.22 There are 3 aspects of this study that may limit generalizability. First, surveys for 3 of the groups were administered at annual association meetings, and it is possible that attendees are more interested in providing high-quality care or represent facilities that have sufficient resources to support travel to such meetings. Second, participants in the survey at the Annual AMDA Symposium are similar to the general AMDA membership with respect to Certificates of Added Qualification in Geriatric Medicine and Certified Medical Director designation, but may differ from nursing facility physicians who are not AMDA members.33 Third, there are substantial differences in the types of homes across the 4 surveyed groups, potentially confounding some of the comparisons across groups. These limitations notwithstanding, 2 important implications emerge from our findings. First, physicians, GNPs, and DONs are much more involved with the other geriatric syndromes, leaving nursing assistants as first-line managers for a condition that NAs perceive as having a significant impact on quality of life. A large retrospective cohort study using an MDS database suggests that the perception of the NAs is correct, even for frail, cognitively impaired residents.19 Second, the perceptions of our respondents that nondrug interventions are not being implemented and that available drugs may not be appropriate for nursing facility residents are consistent with the existing literature and suggest that these barriers must be overcome to realize improved incontinence care. Given the increasingly limited resources in the nursing facility setting, UI may remain the neglected geriatric syndrome. If this is the case, what should physicians, GNPs, DONs, and NAs do to relieve symptoms and improve quality of life for residents with incontinence? Revised interpretive guidelines for incontinence and for the role of the medical director (Tags F315 and F501) may provide an opportunity to address the barriers. State surveyors may focus on the interface between these 2 F Tags in an effort to foster improvement in the recognition, assessment, and management of urinary incontinence. Medical directors can take a leading role in improving continence care by encouraging greater specificity of treatment orders for toileting.34 In addition to developing and implementing policies that call for a search for remediable contributors, medical directors can propose a policy that all new admissions with incontinence or residents with new incontinence receive a 2- to 3-day trial of toileting assistance. Each resident’s response to and preference for toileting assistance can then be documented and used to craft the resident’s individualized care plan.34 Findings from a focus group study of DONs and NAs suggest that there is a desire to foster better team work in implementing toileting programs, especially JAMDA – January 2008

if team-building activities are accompanied by sufficient supplies and easy access to equipment such as lifts and commode chairs.35 While these approaches are only first steps along the path of improved care, they may be important in that they demonstrate to residents, families and surveyors alike the facility’s commitment to improving performance. For example, a randomized, controlled intervention to study continence and mobility suggests that families’ responses to open-ended questions were sensitive to improvements in care.36 Finally, encouraging process improvement teams for UI similar to those seen in many facilities for falls and pressure ulcers may serve to elevate the importance of urinary incontinence for the many nursing facility residents who experience it daily. CONCLUSIONS Physicians, geriatric nurse practitioners, and directors of nursing who care for nursing facility residents are more likely to be involved in evaluating and managing behavioral symptoms of dementia, pain, falls, delirium, and unintended weight loss than urinary incontinence. This leaves nursing assistants as first-line managers for a condition that they perceive, and in fact does, have an important impact on quality of life. Perceived barriers to improving urinary incontinence care differ among the 4 groups suggesting that approaches to overcoming the barriers should be multifaceted. REFERENCES 1. Fultz NH, Herzog AR. Self-reported social and emotional impact of urinary incontinence. J Am Geriatr Soc 2001; 49(7):892– 899. 2. Coyne KS, Zhou Z, Thompson C, Versi E. The impact of health-related quality of life stress, urge and mixed urinary incontinence. BJU Int 2003;92(7):731–735. 3. Irwin De, Milsom I, Kopp Z, Abrams P, Cardozo L. Impact of overactive bladder symptoms on employment, social interactions and emotional wellbeing in six European countries. BJU Int 2006;97(1):96–100. 4. Monz B, Pons ME, Hampel C, et al. Patient-reported impact of urinary incontinence—results from treatment seeking women in 14 European countries. Maturitas 2005;52 Suppl 2:S24 –34. 5. Ko Y, Lin SJ, Salmon JW, Bron MS. The impact of urinary incontinence on quality of life of the elderly. Am J Manag Care 2005;11(4 Suppl):S103– 111. 6. Zorn BH, Montgomery H, Pieper K, Gray M, Steers WD. Urinary incontinence and depression. J Urol 1999;162(1):82– 84. 7. Nygaard I, Turvey C, Burns TL, Crischilles E, Wallace R. Urinary incontinence and depression in middle-aged United States women. Obstet Gynecol 2003;101:149 –156. 8. Stach-Lempinen B, Hakala Al, Laippala, Lehtinen K, Metsanoja R, Kujansuu E. Severe depression determines quality of life in urinary incontinent women. Neurourol Urodyn 2003;22(6):563–568. 9. Melville JL, Delaney K, Newton K, Katon W. Incontinence severity and major depression in incontinent women. Obstet Gynecol 2005;106(3):585– 592. 10. Bliwise DL, Adelman CL, Ouslander JG. Polysomnographic correlates of spontaneous nocturnal wetness episodes in incontinent geriatric patients. Sleep 2004;27(1):153–157. 11. Kaynak H, Kaynak D, Oztura I. Does frequency of nocturnal urination reflect the severity of sleep-disordered breathing? J Sleep Res 2004;13(2): 173–176. 12. Schnelle JF, Adamsom GM, Cruise PA, et al. Skin disorders and moisture in incontinent nursing home residents: intervention implications. J Am Geriatr Soc 1997;45(10):1278 –1279. 13. Zehrer CL, Lutz JB, Hedblom EC, Ding L. A comparison of cost and efficacy of three incontinence skin barrier products. Ostomy Wound Manage 2004;50(12):51–58. ORIGINAL STUDIES

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