- Email: [email protected]
Urinary incontinence
Social Health Maintenance Organization’s Approach (CE) THE
Mary E. Dash, RN, GNP, MSN Emerald B. Foster, PharmD, CGP Diane M. Smith, RN, BS, and Steven L. Phillips, MD, CMD
Urinary incontinence (UI) is a problem that affects more than 16 million Americans, most of them women. Although nearly half of the elderly in America have episodes of UI, it is not a normal consequence of aging. It remains a largely neglected problem despite its considerable prevalence, morbidity, and expense. This article reports on a successful proactive health risk screening process to treat this major problem. (Geriatr Nurs 2004;25:81-89)
March/April 2004
81
rs. W is a 77-year-old woman referred for evaluation of urinary incontinence (UI). Her medical history includes hypertension, hypothyroidism, and hyperlipidemia, as well as five vaginal deliveries. She takes a diuretic and Premarin 0.625 mg daily (Wyeth-Ayerst, Philadelphia). Mrs. W says she tried taking oxybutynin for her UI several years ago. It was helpful but caused very severe mouth dryness, so she quit taking it. She says she has had a problem with UI for approximately 10 years, with gradual worsening. She further relates symptoms of loss of urine when she coughs, sneezes, or lifts and complains of inability to hold her urine. These problems occur during both daytime and nighttime. The inability to hold her urine is much more bothersome than the loss of urine experienced when she coughs. She usually has three to four incontinent episodes during the day and approximately two incontinent episodes at night. She says she has to get up two or three times a night to urinate, and her bed is close to the bathroom. On average she drinks approximately five to six glasses of water or juice per day and one glass of water before bed. She drinks decaffeinated products except for one cup of regular coffee in the morning and denies pain or burning on urination. Mrs. W uses pull-on incontinence underwear for her problem but says they are not effective. She indicates that, when she has an accident, urine leaks down the inside and outside of her leg and she has difficulty keeping the incontinence underwear up. She ambulates with a tri-wheel walker with much difficulty; her gait is slow and wide based. She also has difficulty raising and lowering herself from a chair. Physical examination does not reveal bladder distention on palpation of the suprapubic area or atrophic vaginitis on pelvic examination. No rectocele or cystocele is noted on the Valsalva maneuver. Rectal examination reveals good anal sphincter tone. This evaluation determines that Mrs. W has a combination of both urge and stress incontinence. She is encouraged
M
Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 88.
On completion of this article, the reader should be able to: 1. Decribe the approach to screen, assess and treat urinary incontinence. 2. Discuss the benefits of using a team approach to urinary incontinence. 3. Describe various assessment tools used for identifying urinary incontinence.
82
Table 1. Risk Factors for Urinary Incontinence Immobility/degenerative disease Impaired cognition (lack of awareness of need to use toilet) Medications (anticholinergic properties, sedatives, diuretics) Morbid obesity Smoking Fecal impaction Delirium Low fluid intake (UI is difficult to detect in dehydrated patients) Environmental barriers High-impact physical activities (contributes to stress incontinence)
Diabetes (urinary frequency) Stroke
Estrogen depletion (atrophic vaginitis) Pelvic muscle weakness Childhood nocturnal enuresis Race (reported more frequently by whites) Pregnancy/vaginal delivery/ episiotomy Amount and timing of fluid consumption Caffeine intake Alcohol consumption
to decrease or stop fluids after her evening meal to help decrease her need to go to the bathroom during the night, as well as urinate every 2 to 3 hours while awake. She is started on Ditropan XL 5 mg daily (ALZA, Mountain View, CA). In addition, instructions on correctly performing Kegel exercises for stress incontinence are provided, including written instructions for future reference. She says she has tried the exercises previously, but after the current instruction session, she realizes she was not performing them correctly. A suggestion is made to try wearing a pair of cotton underwear over the incontinence underwear along with a pad to help absorb escaping urine. A toilet riser with arms is ordered to assist with transfers from the toilet. At the 4-week follow-up, Mrs. W reports a decrease in her incontinence episodes to fewer than three or four per week and a decrease in her nocturia to an average of only once a night with no further problems with nighttime incontinence. She says she has continued to perform the Kegel exercises three times a day for the stress incontinence. However, she feels her stress symptoms have not improved at this point. The addition of cotton underwear and pads has been very effective in containing the urine when she does experience an incontinent episode.
UI Overview This case report is not unique. UI is a problem that affects more than 16 million Americans, 85% of whom are women.1 Although nearly half of American elders have incontinent episodes, UI is not a normal consequence of aging. Despite its considerable prevalence, morbidity, and
Geriatric Nursing
Volume 25
Number 2
Table 2. Urinary Incontinence Guidelines Definition Diagnosis
One or more urinary accidents in past month or complaints about the problem 1. Evaluate presence of: a. Diabetes b. CHF c. Neurological lesions d. Post GU surgery 2. History (onset, pattern, fluid intake) 3. Physical exam including: a. Pelvic (female) b. Prostate (male) c. Urinalysis to rule out hematuria, infection d. Postvoid residual Treatment 4.Treat acute/episodic causes: a. Delirium b. Infection c. Atrophic vaginitis d. Pharmaceuticals i. Retention overflow 1. Antidepressants 2. Antipsychotics 3. Antidiarrhea drugs 4. Antiparkinsonian drugs 5. Decongestants 6. Calcium channel blockers 7. Alpha agonists (men) ii. Urge incontinence 1. Alpha blockers 2. Diuretics 3. Parasympathomimetics e. Psychological f. Endocrine g. Restricted mobility h. Stool impaction 5.Treat chronic causes according to type: a. Storage disorders—bladder size normal i. Urge incontinence (detrusor overactivity): frequent voids, dry in between, variable amounts of leakage; treat with behavioral techniques, anticholinergics ii. Stress incontinence: small leakage with cough, sneeze, etc.; treat with behavioral techniques, alpha agonists, estrogens, surgery, periurethral injection, pessary iii. Mixed (stress and urge): both symptoms/signs; treat with behavioral techniques, estrogens and imipramine, pessary b. Emptying disorders: distended bladder causes overflow incontinence; slow stream; frequent, small leakage; strain; hesitancy i. Detrusor underactivity: treat by maximizing cholinergic tone, avoid alpha stimulation ii. Outlet obstruction: treat with alpha blockade, 5-alpha reductase inhibitors, transurethral resection of prostate, urethral dilation Stress Estrogen: Cream 1 g/d vaginally, 5x/wk Incontinence Oral 0.3-0.625 mg/day Medications Plus continued Alpha agonist (phenylpropanolamine 60 mg bid)
March/April 2004
83
Table 2. Urinary Incontinence Guidelines (continued) OR
Pseudoephedrine 30-60 mg tid OR
Behavioral Techniques
Imipramine 10-25 mg tid Scheduled voiding Habit training Pelvic strengthening (Kegel) Exercises Bladder drill (expand time between voids) Adequate/appropriate fluid intake Oxybutynin 2.5mg qd - 5 mg tid
Urge Incontinence OR Medications Imipramine 10-25 mg tid OR
Monitoring
Ditropan XL 5-10 mg/day Depends on treatment plan and patient response
expense, UI remains a largely neglected problem. Many incontinent individuals dismiss it as a normal process of aging, and only a minority seek help or even confide this problem to their health care professionals.2 When incontinence is brought to a provider’s attention, it is often inadequately evaluated. Incontinence is abnormal at any age, and regardless of a person’s age, mobility, mental status, or frailty, the condition is usually treatable and often can be improved or even resolved. For assessment and management purposes, UI has several causes that are categorized by symptoms: • Stress incontinence occurs when there is a small amount of urine leakage associated with such effort as coughing, sneezing, or physical activity.3 • Overflow incontinence involves difficulty in initiating urination, a weak or intermittent stream, and postvoid dribbling. Other symptoms include an increase in voiding time, a sensation of fullness after voiding, and dribbling with changes in position. • Urge incontinence is associated with a sudden strong desire to void and results in moderate to large amounts of urine loss, urinary frequency, nocturia, and enuresis. • Functional incontinence’s factors include impaired mobility, manual dexterity, and multiple other factors.4 When a person is unable to use toilet facilities because of mobility problems in getting to a toilet or transferring to it, or she is unable to remove her clothing fast enough to urinate, functional incontinence can occur. It also can happen in individuals with impaired mental function who may not recognize the need to use a toilet or are unwilling to use it.5
84
Table 1 lists several UI risk factors. Sierra Health Services, Inc., through Health Plan of Nevada and the Second Generation Social HMO Demonstration Project, has approached UI proactively through a health risk screening process. All plan members identified for probable UI are contacted by the care coordination team, which performs a secondary risk screen. Individuals who respond affirmatively to the secondary risk screen are referred to the Southwest Medical Associates’ department of geriatrics and the Urinary Incontinence Clinic. This clinic is managed by a geriatric advanced nurse practitioner who works directly with a nurse case manager, social worker, and clinical pharmacist. A geriatrician responsible for the clinical activities in the department of geriatrics also collaborates. The guidelines presented by the Agency for Health Care Policy and Research in March 1996 from the Department of Health and Human Services, Public Health Service, formed the basis for the protocol for UI screening, assessment, and treatment in this clinic.6 Individuals are assessed for contributing medical problems, medication-related adverse effects, mobility/functional impairments, and cognitive function to determine appropriate interventions. The goals of the clinic are to resolve or improve urinary incontinence; educate the patient, family/caregiver, and referring health care professionals on the disorder in terms of potential causes and treatment options; and assist the patient or family caregiver with problem-solving strategies when appropriate.7 The Urinary Incontinence Clinic uses established clinical guidelines developed in association with Southwest Medical Associates, along with a tool referred to as Assessment of Urinary Elimination, shown in Tables 2 and 3, respectively.
Geriatric Nursing
Volume 25
Number 2
Table 3. Assessment of Urinary Elimination
Instructions: Complete the form for patients who are incontinent. For each question circle the appropriate response. Patient Name: BD/Age:
Date: Gender:
Diagnosis: Medications:
HISTORY a. Recent onset within past 6 months b. Onset within past 3 years c. Persistent problem for > 3 years 2. Frequency a. Once a day or less b. At least once and up to twice a day c.Three times a day or more d. Nighttime only 3. Severity a. Small amounts of urine loss b. Moderate amounts of urine loss c. Large amounts of urine loss 4. Risk Factors a. Smoking d. Fluid intake inadequate b. Caffeine intake e. Chronic constipation c. Alcohol f. Obesity 5. Psychological Impact a. Concerned about UI d. Cost of managing UI burdensome b. Not concerned w/UI because e. Major change in lifestyle it’s well managed f. Social/family relationship adversely affected c. Unaware of/denies UI 6. Medical History a. Stroke g. Multiple or difficult vaginal deliveries b. Parkinson’s Disease h. Pelvic surgery c. Dementia i. Pernicious anemia d. CHF j. Multiple Sclerosis e. Diabetes mellitus k. Kidney disease, stones, recurrent infection f. Diabetes insipidus l. Back injury or surgery 7. Current Management a. Pads/incontinence underwear d. Medication b.Toileting regimen e. Skin care c. Catheters or devices 8. Incontinence Symptom Profile —Stress UI a. Leakage with cough, sneeze, c. No nocturia or UI at night physical activity d. UI without sensation of urine loss b. UI in small amounts (drops, spurts) —Urge UI a. Strong, uncontrolled urge prior d. Nocturia > 2 to UI e. Enuresis b. Moderate/large volume of urine loss (gush) c. Frequency of urination —Overflow UI a. Difficulty starting urine stream d. Feeling of fullness after voiding b.Weak or intermittent stream e.Voiding in small amount often or dribbling (dribbles) with changes in position c. Postvoid dribbling —Functional UI a. Mobility or manual dexterity impairments b. Sedative, hypnotic, CNS depressant, diuretic, anticholinergic, alpha adrenergic antagonist c. Depression, delirium, dementia d. Pain PHYSICAL EXAM 1. Abdominal Exam a. Normal c. Abdominal masses b. Palpable bladder d. Distended bowel 1. Onset
continued
March/April 2004
85
Table 3. continued
2. Genitalia
3. Pelvic Exams —Vaginal Inspection
—Pelvis Muscle Assessment 4. Rectal Exam
1. Mobility
2. Manual Dexterity
3. Cognitive Function
a. Normal b. Reddened, irritated tissue c. Discharge
d. Infection e. Odor f. Lesions
a. Normal d. Lesions b.Tissue pale, thin, dry c. Pelvic organ descent with Valsalva a. Palpable, voluntary contraction, rating 0-5: b. Unable to elicit voluntary contraction a. Snug anal sphincter tone and good sensation b. Lax or absent anal sphincter tone c. Fecal impaction FUNCTIONAL ASSESSMENT a. Can toilet without assistance b. Needs assistance or verbal prompting to toilet c. Unable a. Independent b. Needs assistance c. Unable a. Intact b. Impaired—Mini Mental State Exam Score: (< 24 abnormal) CLINICAL IMPRESSION
Table 4. Medications that Can Contribute to Urinary Incontinence Medication Anticholinergics: psychotropics, antidepressants, disopyramide, antispasmodics, anti-Parkinson agents Diuretics Sedatives Psychopharmacologic agents: antipsychotics, antidepressants, sedatives/hypnotics, anxiolytics Alpha-adrenergic blockers Alpha-adrenergic agonists Calcium channel blockers Alcohol Muscle relaxants Caffeine
86
Mechanism
Signs/Symptoms
Detrusor relaxation
Hesitancy, straining to void, overflow incontinence
Increased urine volume Sedation, obtundation Sedation, anticholinergic
Polyuria, frequency, urgency, confusion, delirium Confusion, delirium Hesitancy, straining to void, overflow incontinence, confusion, delirium
Decreased urethral resistance Increased urethral resistance
Stress incontinence Hesitancy, straining to void, overflow incontinence, confusion Detrusor relaxation, increased Hesitancy, straining to void, overflow incontinence, residual volume confusion Increased urinary volume, Urgency, frequency, nocturia, sedation, confusion, sedation, altered mental state immobility Urethral sphincter relaxation Polyuria, frequency, urgency Diuresis (increased urine volume) Polyuria, frequency, urgency, confusion, delirium
Geriatric Nursing
Volume 25
Number 2
A focused history and physical examination are conducted to detect reversible and contributing factors. Possible reversible factors include the following: • Patient condition (delirium, fecal impaction, depression, urinary tract infection) • Environmental conditions (impaired mobility, lack of access to a toilet, restrictive clothing) • Amount and timing of fluid intake and caffeine consumption • Disease states (diabetes, hypercalcemia, Parkinson’s and other neurologic processes that affect motor skills) • Medications (diuretics, psychoactive medications, and other drugs that stimulate or block the sympathetic nervous system). Other contributing factors may include pain, atrophic vaginitis, cancer of the bladder or prostate, urethral obstruction, and disorders of the brain or spinal cord.8 As part of the assessment, a pharmacist reviews all medications (prescription and over the counter) to determine their potential for causing or contributing to UI. As listed in Table 4, several types of medications can cause or contribute to UI. The discontinuation of certain medications (eg, anticholinergics, sedatives) or the addition of others (eg. antispasmodics, estrogen replacement) can have a major impact on the resolution and management of several forms of incontinence. In this program, the clinical pharmacist also provides ongoing evaluation and monitoring of the medications initiated or discontinued to treat UI. Once the contributing factors have been identified, a treatment plan is developed. Reversible factors, such as fecal impaction, urinary tract infections, or medications, are addressed. A management plan is developed with appropriate pharmacologic and nonpharmacologic interventions for nonreversible contributing factors (eg, neurologic deficits and impaired mobility). Education remains the basis for the program’s success. The patient and family caregivers are taught the anatomy and physiology of the problem and the plan to help rectify it. Aspects of the treatment plan, such as Kegel exercises, are explained through both verbal and written instructions, and the patient is given an opportunity to demonstrate and receive feedback. Written handouts on recommendations for lifestyle changes, such as fluid consumption and caffeine intake, are available for the patient to take home. Once a treatment plan is established, a routine follow-up consisting of an office visit or telephone contact is made within 3 to 4 weeks, depending on patient preference. Patients are encouraged to communicate any problems with the medication or treatment plan as soon as a concern arises. Patients are seen in a follow-up visit if the issue cannot be resolved over the telephone.
March/April 2004
REFERENCES 1. Resnick NM, Ouslander JG, editors. Proceedings of the National Institutes of Health consensus development conference on urinary incontinence. J Am Geriatr Soc 1990;38:263-386. 2. Chery N. Defects in aspects of the urinary system have severe consequences, Geriatr Aging 2000;3:8,13. 3. Stothers L, Fenster H. Urinary incontinence in the elderly. Geriatr Aging 2002;5:35-9. 4. Ouslander JG. Incontinence. In: Kane RL, Ouslander JG, Abrass IB, editors. Essentials of clinical geriatrics. 2nd ed. New York: McGraw-Hill; 1998. 5. Dubean CE, Resnick NM. Evaluation of the causes and severity of geriatric incontinence—a critical appraisal. Urol Clin North Am 1991;18(2):243. 6. Agency for Health Care Policy and Research. Overview: incontinence in adults, clinical practice guidelines update. March 1996. Available at: www.ahrq.gov/news/press/uiovervw.htm.. 7. Newman DK. Managing and treating urinary incontinence. Baltimore: Health Professions Press; 2002. 8. Aronheim JC. Treatment of urinary bladder disturbances. In: Handbook of prescribing medications for elderly patients. Boston: Little, Brown and Co.; 1992. p. 313-23.
MARY E. DASH, RN, GNP, MSN, is clinical manager of the department of geriatrics at Southwest Medical Associates in Las Vegas, Nevada. EMERALD B. FOSTER, PharmD, CGP, is manager of geriatric pharmacy services, DIANE M. SMITH, RN, BS, is vice president of care coordination, and STEVEN L. PHILLIPS, MD, CMD, is medical director of Senior Dimensions Extended Care, all at Sierra Health Services, Inc./Health Plan of Nevada in Las Vegas. Acknowledgments The authors acknowledge the assistance of Aurelio J. Muyot, MD, Sherry Coffman, APN, and Debra Fulfer, RN, and thank Joann Phillips for manuscript preparation. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2003.10.021
87
CE
Contact hours: 1 Minimum passing score: 70% Test processing fee: $9 Test ID: GN0404
1. Urinary incontinence affects: A. Mostly men B. Mostly women C. Only the elderly D. Only those with dementia
7. The success of this program rests with: A. Identifying the right population B. Patient education C. Thorough nutritional analysis D. The use of new medications
2. Coughing or sneezing that causes a small amount of urine to leak is identified as: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence
Match the following medication with their resulting symptoms:
3. When a person cannot remove their clothing quickly enough to sit on the toilet in time, this type of incontinence is referred to as: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence 4. Difficulty in urinating or post-voiding dribbling is referred to as: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence 5. Nocturia, enuresis and moderate or large amounts of urine loss is called: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence 6. The clinic team described in this article is comprised of all the following specialties except: A. Case manager B. Social worker C. Pharmacist D. Urologist
88
8. anticholinergics A. stress incontinence B. functional incontinence C. overflow incontinence D. urge incontinence 9. alpha adrenergic blockers A. stress incontinence B. functional incontinence C. overflow incontinence D. urge incontinence 10. alcohol A. stress incontinence B. functional incontinence C. overflow incontinence D. urge incontinence 11. Which medication is NOT listed as causing overflow incontinence: A. Psychopharmacologics B. Calcium channel blockers C. Anticholinergics D. Muscle relaxants 12. Detrusor overactivity is associated with: A. Urge incontinence B. Stress incontinence C. Urge incontinence D. Outlet obstruction
Geriatric Nursing
Volume 25
Number 2
CE ANSWER/ENROLLMENT FORM To receive continuing education credit for any test in this issue, simply do the following: 1. Read the article. 2. Take the test for the article and record your answers on the form below. (You may make copies of the answer form.) You should complete one answer form for EACH test. 3. Mail the completed answer/enrollment form along with a check or money order. Payment must be included for your examination to be processed. 4. The deadline for submitting your answer/enrollment form is 2 years from the date of this issue. 5. Your results will be sent within 4 weeks after your answer form is received. Enrollees who have a passing score will receive a certificate. Instructions: Mark your answers clearly by placing an “x” in the box next to the correct answer. This is a standard form; use only the number of spaces required for the test you are taking. Test I.D. No. 1.
❑A ❑B ❑C ❑D
11. ❑ A ❑B ❑C ❑D
2.
❑A ❑B ❑C ❑D
12. ❑ A ❑B ❑C ❑D
3.
❑A ❑B ❑C ❑D
13. ❑ A ❑B ❑C ❑D
4.
❑A ❑B ❑C ❑D
14. ❑ A ❑B ❑C ❑D
5.
❑A ❑B ❑C ❑D
15. ❑ A ❑B ❑C ❑D
6.
❑A ❑B ❑C ❑D
16. ❑ A ❑B ❑C ❑D
Name
7.
❑A ❑B ❑C ❑D
17. ❑ A ❑B ❑C ❑D
8.
❑A ❑B ❑C ❑D
18. ❑ A ❑B ❑C ❑D
9.
❑A ❑B ❑C ❑D
10. ❑ A ❑B ❑C ❑D
19. ❑ A ❑B ❑C ❑D
20. ❑ A ❑B ❑C ❑D
Credentials
Address
City
ZIP
State
Social Security No.
Phone Mail to:
License: State/No. Elsevier Attn: Gina Clites 11830 Westline Industrial Drive St. Louis, MO 63146 For more information call: (800) 325-4177, ext. 4810
Mosby Continuing Education and Training (CET) is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC-COA). This approval is reciprocal in all states and for all speciality organizations that recognize the ANCC approval process. Mosby CET is also a certified provider of nursing continuing education in California (Provider No. CEP03257).
PROGRAM EVALUATION
Strongly agree Strongly Disagree 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— Easy Difficult How long did this program take to complete? hours ❑ I have enclosed an additional $10 for rush processing.
The objectives of the program were met. The content was appropriate. My expectations have been met. This form of CE is worthwhile. The level of difficulty of this test was:
❑ I have enclosed an additional $15 for foreign delivery.
March/April 2004
89
Mary E. Dash, RN, GNP, MSN Emerald B. Foster, PharmD, CGP Diane M. Smith, RN, BS, and Steven L. Phillips, MD, CMD
Urinary incontinence (UI) is a problem that affects more than 16 million Americans, most of them women. Although nearly half of the elderly in America have episodes of UI, it is not a normal consequence of aging. It remains a largely neglected problem despite its considerable prevalence, morbidity, and expense. This article reports on a successful proactive health risk screening process to treat this major problem. (Geriatr Nurs 2004;25:81-89)
March/April 2004
81
rs. W is a 77-year-old woman referred for evaluation of urinary incontinence (UI). Her medical history includes hypertension, hypothyroidism, and hyperlipidemia, as well as five vaginal deliveries. She takes a diuretic and Premarin 0.625 mg daily (Wyeth-Ayerst, Philadelphia). Mrs. W says she tried taking oxybutynin for her UI several years ago. It was helpful but caused very severe mouth dryness, so she quit taking it. She says she has had a problem with UI for approximately 10 years, with gradual worsening. She further relates symptoms of loss of urine when she coughs, sneezes, or lifts and complains of inability to hold her urine. These problems occur during both daytime and nighttime. The inability to hold her urine is much more bothersome than the loss of urine experienced when she coughs. She usually has three to four incontinent episodes during the day and approximately two incontinent episodes at night. She says she has to get up two or three times a night to urinate, and her bed is close to the bathroom. On average she drinks approximately five to six glasses of water or juice per day and one glass of water before bed. She drinks decaffeinated products except for one cup of regular coffee in the morning and denies pain or burning on urination. Mrs. W uses pull-on incontinence underwear for her problem but says they are not effective. She indicates that, when she has an accident, urine leaks down the inside and outside of her leg and she has difficulty keeping the incontinence underwear up. She ambulates with a tri-wheel walker with much difficulty; her gait is slow and wide based. She also has difficulty raising and lowering herself from a chair. Physical examination does not reveal bladder distention on palpation of the suprapubic area or atrophic vaginitis on pelvic examination. No rectocele or cystocele is noted on the Valsalva maneuver. Rectal examination reveals good anal sphincter tone. This evaluation determines that Mrs. W has a combination of both urge and stress incontinence. She is encouraged
M
Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 88.
On completion of this article, the reader should be able to: 1. Decribe the approach to screen, assess and treat urinary incontinence. 2. Discuss the benefits of using a team approach to urinary incontinence. 3. Describe various assessment tools used for identifying urinary incontinence.
82
Table 1. Risk Factors for Urinary Incontinence Immobility/degenerative disease Impaired cognition (lack of awareness of need to use toilet) Medications (anticholinergic properties, sedatives, diuretics) Morbid obesity Smoking Fecal impaction Delirium Low fluid intake (UI is difficult to detect in dehydrated patients) Environmental barriers High-impact physical activities (contributes to stress incontinence)
Diabetes (urinary frequency) Stroke
Estrogen depletion (atrophic vaginitis) Pelvic muscle weakness Childhood nocturnal enuresis Race (reported more frequently by whites) Pregnancy/vaginal delivery/ episiotomy Amount and timing of fluid consumption Caffeine intake Alcohol consumption
to decrease or stop fluids after her evening meal to help decrease her need to go to the bathroom during the night, as well as urinate every 2 to 3 hours while awake. She is started on Ditropan XL 5 mg daily (ALZA, Mountain View, CA). In addition, instructions on correctly performing Kegel exercises for stress incontinence are provided, including written instructions for future reference. She says she has tried the exercises previously, but after the current instruction session, she realizes she was not performing them correctly. A suggestion is made to try wearing a pair of cotton underwear over the incontinence underwear along with a pad to help absorb escaping urine. A toilet riser with arms is ordered to assist with transfers from the toilet. At the 4-week follow-up, Mrs. W reports a decrease in her incontinence episodes to fewer than three or four per week and a decrease in her nocturia to an average of only once a night with no further problems with nighttime incontinence. She says she has continued to perform the Kegel exercises three times a day for the stress incontinence. However, she feels her stress symptoms have not improved at this point. The addition of cotton underwear and pads has been very effective in containing the urine when she does experience an incontinent episode.
UI Overview This case report is not unique. UI is a problem that affects more than 16 million Americans, 85% of whom are women.1 Although nearly half of American elders have incontinent episodes, UI is not a normal consequence of aging. Despite its considerable prevalence, morbidity, and
Geriatric Nursing
Volume 25
Number 2
Table 2. Urinary Incontinence Guidelines Definition Diagnosis
One or more urinary accidents in past month or complaints about the problem 1. Evaluate presence of: a. Diabetes b. CHF c. Neurological lesions d. Post GU surgery 2. History (onset, pattern, fluid intake) 3. Physical exam including: a. Pelvic (female) b. Prostate (male) c. Urinalysis to rule out hematuria, infection d. Postvoid residual Treatment 4.Treat acute/episodic causes: a. Delirium b. Infection c. Atrophic vaginitis d. Pharmaceuticals i. Retention overflow 1. Antidepressants 2. Antipsychotics 3. Antidiarrhea drugs 4. Antiparkinsonian drugs 5. Decongestants 6. Calcium channel blockers 7. Alpha agonists (men) ii. Urge incontinence 1. Alpha blockers 2. Diuretics 3. Parasympathomimetics e. Psychological f. Endocrine g. Restricted mobility h. Stool impaction 5.Treat chronic causes according to type: a. Storage disorders—bladder size normal i. Urge incontinence (detrusor overactivity): frequent voids, dry in between, variable amounts of leakage; treat with behavioral techniques, anticholinergics ii. Stress incontinence: small leakage with cough, sneeze, etc.; treat with behavioral techniques, alpha agonists, estrogens, surgery, periurethral injection, pessary iii. Mixed (stress and urge): both symptoms/signs; treat with behavioral techniques, estrogens and imipramine, pessary b. Emptying disorders: distended bladder causes overflow incontinence; slow stream; frequent, small leakage; strain; hesitancy i. Detrusor underactivity: treat by maximizing cholinergic tone, avoid alpha stimulation ii. Outlet obstruction: treat with alpha blockade, 5-alpha reductase inhibitors, transurethral resection of prostate, urethral dilation Stress Estrogen: Cream 1 g/d vaginally, 5x/wk Incontinence Oral 0.3-0.625 mg/day Medications Plus continued Alpha agonist (phenylpropanolamine 60 mg bid)
March/April 2004
83
Table 2. Urinary Incontinence Guidelines (continued) OR
Pseudoephedrine 30-60 mg tid OR
Behavioral Techniques
Imipramine 10-25 mg tid Scheduled voiding Habit training Pelvic strengthening (Kegel) Exercises Bladder drill (expand time between voids) Adequate/appropriate fluid intake Oxybutynin 2.5mg qd - 5 mg tid
Urge Incontinence OR Medications Imipramine 10-25 mg tid OR
Monitoring
Ditropan XL 5-10 mg/day Depends on treatment plan and patient response
expense, UI remains a largely neglected problem. Many incontinent individuals dismiss it as a normal process of aging, and only a minority seek help or even confide this problem to their health care professionals.2 When incontinence is brought to a provider’s attention, it is often inadequately evaluated. Incontinence is abnormal at any age, and regardless of a person’s age, mobility, mental status, or frailty, the condition is usually treatable and often can be improved or even resolved. For assessment and management purposes, UI has several causes that are categorized by symptoms: • Stress incontinence occurs when there is a small amount of urine leakage associated with such effort as coughing, sneezing, or physical activity.3 • Overflow incontinence involves difficulty in initiating urination, a weak or intermittent stream, and postvoid dribbling. Other symptoms include an increase in voiding time, a sensation of fullness after voiding, and dribbling with changes in position. • Urge incontinence is associated with a sudden strong desire to void and results in moderate to large amounts of urine loss, urinary frequency, nocturia, and enuresis. • Functional incontinence’s factors include impaired mobility, manual dexterity, and multiple other factors.4 When a person is unable to use toilet facilities because of mobility problems in getting to a toilet or transferring to it, or she is unable to remove her clothing fast enough to urinate, functional incontinence can occur. It also can happen in individuals with impaired mental function who may not recognize the need to use a toilet or are unwilling to use it.5
84
Table 1 lists several UI risk factors. Sierra Health Services, Inc., through Health Plan of Nevada and the Second Generation Social HMO Demonstration Project, has approached UI proactively through a health risk screening process. All plan members identified for probable UI are contacted by the care coordination team, which performs a secondary risk screen. Individuals who respond affirmatively to the secondary risk screen are referred to the Southwest Medical Associates’ department of geriatrics and the Urinary Incontinence Clinic. This clinic is managed by a geriatric advanced nurse practitioner who works directly with a nurse case manager, social worker, and clinical pharmacist. A geriatrician responsible for the clinical activities in the department of geriatrics also collaborates. The guidelines presented by the Agency for Health Care Policy and Research in March 1996 from the Department of Health and Human Services, Public Health Service, formed the basis for the protocol for UI screening, assessment, and treatment in this clinic.6 Individuals are assessed for contributing medical problems, medication-related adverse effects, mobility/functional impairments, and cognitive function to determine appropriate interventions. The goals of the clinic are to resolve or improve urinary incontinence; educate the patient, family/caregiver, and referring health care professionals on the disorder in terms of potential causes and treatment options; and assist the patient or family caregiver with problem-solving strategies when appropriate.7 The Urinary Incontinence Clinic uses established clinical guidelines developed in association with Southwest Medical Associates, along with a tool referred to as Assessment of Urinary Elimination, shown in Tables 2 and 3, respectively.
Geriatric Nursing
Volume 25
Number 2
Table 3. Assessment of Urinary Elimination
Instructions: Complete the form for patients who are incontinent. For each question circle the appropriate response. Patient Name: BD/Age:
Date: Gender:
Diagnosis: Medications:
HISTORY a. Recent onset within past 6 months b. Onset within past 3 years c. Persistent problem for > 3 years 2. Frequency a. Once a day or less b. At least once and up to twice a day c.Three times a day or more d. Nighttime only 3. Severity a. Small amounts of urine loss b. Moderate amounts of urine loss c. Large amounts of urine loss 4. Risk Factors a. Smoking d. Fluid intake inadequate b. Caffeine intake e. Chronic constipation c. Alcohol f. Obesity 5. Psychological Impact a. Concerned about UI d. Cost of managing UI burdensome b. Not concerned w/UI because e. Major change in lifestyle it’s well managed f. Social/family relationship adversely affected c. Unaware of/denies UI 6. Medical History a. Stroke g. Multiple or difficult vaginal deliveries b. Parkinson’s Disease h. Pelvic surgery c. Dementia i. Pernicious anemia d. CHF j. Multiple Sclerosis e. Diabetes mellitus k. Kidney disease, stones, recurrent infection f. Diabetes insipidus l. Back injury or surgery 7. Current Management a. Pads/incontinence underwear d. Medication b.Toileting regimen e. Skin care c. Catheters or devices 8. Incontinence Symptom Profile —Stress UI a. Leakage with cough, sneeze, c. No nocturia or UI at night physical activity d. UI without sensation of urine loss b. UI in small amounts (drops, spurts) —Urge UI a. Strong, uncontrolled urge prior d. Nocturia > 2 to UI e. Enuresis b. Moderate/large volume of urine loss (gush) c. Frequency of urination —Overflow UI a. Difficulty starting urine stream d. Feeling of fullness after voiding b.Weak or intermittent stream e.Voiding in small amount often or dribbling (dribbles) with changes in position c. Postvoid dribbling —Functional UI a. Mobility or manual dexterity impairments b. Sedative, hypnotic, CNS depressant, diuretic, anticholinergic, alpha adrenergic antagonist c. Depression, delirium, dementia d. Pain PHYSICAL EXAM 1. Abdominal Exam a. Normal c. Abdominal masses b. Palpable bladder d. Distended bowel 1. Onset
continued
March/April 2004
85
Table 3. continued
2. Genitalia
3. Pelvic Exams —Vaginal Inspection
—Pelvis Muscle Assessment 4. Rectal Exam
1. Mobility
2. Manual Dexterity
3. Cognitive Function
a. Normal b. Reddened, irritated tissue c. Discharge
d. Infection e. Odor f. Lesions
a. Normal d. Lesions b.Tissue pale, thin, dry c. Pelvic organ descent with Valsalva a. Palpable, voluntary contraction, rating 0-5: b. Unable to elicit voluntary contraction a. Snug anal sphincter tone and good sensation b. Lax or absent anal sphincter tone c. Fecal impaction FUNCTIONAL ASSESSMENT a. Can toilet without assistance b. Needs assistance or verbal prompting to toilet c. Unable a. Independent b. Needs assistance c. Unable a. Intact b. Impaired—Mini Mental State Exam Score: (< 24 abnormal) CLINICAL IMPRESSION
Table 4. Medications that Can Contribute to Urinary Incontinence Medication Anticholinergics: psychotropics, antidepressants, disopyramide, antispasmodics, anti-Parkinson agents Diuretics Sedatives Psychopharmacologic agents: antipsychotics, antidepressants, sedatives/hypnotics, anxiolytics Alpha-adrenergic blockers Alpha-adrenergic agonists Calcium channel blockers Alcohol Muscle relaxants Caffeine
86
Mechanism
Signs/Symptoms
Detrusor relaxation
Hesitancy, straining to void, overflow incontinence
Increased urine volume Sedation, obtundation Sedation, anticholinergic
Polyuria, frequency, urgency, confusion, delirium Confusion, delirium Hesitancy, straining to void, overflow incontinence, confusion, delirium
Decreased urethral resistance Increased urethral resistance
Stress incontinence Hesitancy, straining to void, overflow incontinence, confusion Detrusor relaxation, increased Hesitancy, straining to void, overflow incontinence, residual volume confusion Increased urinary volume, Urgency, frequency, nocturia, sedation, confusion, sedation, altered mental state immobility Urethral sphincter relaxation Polyuria, frequency, urgency Diuresis (increased urine volume) Polyuria, frequency, urgency, confusion, delirium
Geriatric Nursing
Volume 25
Number 2
A focused history and physical examination are conducted to detect reversible and contributing factors. Possible reversible factors include the following: • Patient condition (delirium, fecal impaction, depression, urinary tract infection) • Environmental conditions (impaired mobility, lack of access to a toilet, restrictive clothing) • Amount and timing of fluid intake and caffeine consumption • Disease states (diabetes, hypercalcemia, Parkinson’s and other neurologic processes that affect motor skills) • Medications (diuretics, psychoactive medications, and other drugs that stimulate or block the sympathetic nervous system). Other contributing factors may include pain, atrophic vaginitis, cancer of the bladder or prostate, urethral obstruction, and disorders of the brain or spinal cord.8 As part of the assessment, a pharmacist reviews all medications (prescription and over the counter) to determine their potential for causing or contributing to UI. As listed in Table 4, several types of medications can cause or contribute to UI. The discontinuation of certain medications (eg, anticholinergics, sedatives) or the addition of others (eg. antispasmodics, estrogen replacement) can have a major impact on the resolution and management of several forms of incontinence. In this program, the clinical pharmacist also provides ongoing evaluation and monitoring of the medications initiated or discontinued to treat UI. Once the contributing factors have been identified, a treatment plan is developed. Reversible factors, such as fecal impaction, urinary tract infections, or medications, are addressed. A management plan is developed with appropriate pharmacologic and nonpharmacologic interventions for nonreversible contributing factors (eg, neurologic deficits and impaired mobility). Education remains the basis for the program’s success. The patient and family caregivers are taught the anatomy and physiology of the problem and the plan to help rectify it. Aspects of the treatment plan, such as Kegel exercises, are explained through both verbal and written instructions, and the patient is given an opportunity to demonstrate and receive feedback. Written handouts on recommendations for lifestyle changes, such as fluid consumption and caffeine intake, are available for the patient to take home. Once a treatment plan is established, a routine follow-up consisting of an office visit or telephone contact is made within 3 to 4 weeks, depending on patient preference. Patients are encouraged to communicate any problems with the medication or treatment plan as soon as a concern arises. Patients are seen in a follow-up visit if the issue cannot be resolved over the telephone.
March/April 2004
REFERENCES 1. Resnick NM, Ouslander JG, editors. Proceedings of the National Institutes of Health consensus development conference on urinary incontinence. J Am Geriatr Soc 1990;38:263-386. 2. Chery N. Defects in aspects of the urinary system have severe consequences, Geriatr Aging 2000;3:8,13. 3. Stothers L, Fenster H. Urinary incontinence in the elderly. Geriatr Aging 2002;5:35-9. 4. Ouslander JG. Incontinence. In: Kane RL, Ouslander JG, Abrass IB, editors. Essentials of clinical geriatrics. 2nd ed. New York: McGraw-Hill; 1998. 5. Dubean CE, Resnick NM. Evaluation of the causes and severity of geriatric incontinence—a critical appraisal. Urol Clin North Am 1991;18(2):243. 6. Agency for Health Care Policy and Research. Overview: incontinence in adults, clinical practice guidelines update. March 1996. Available at: www.ahrq.gov/news/press/uiovervw.htm.. 7. Newman DK. Managing and treating urinary incontinence. Baltimore: Health Professions Press; 2002. 8. Aronheim JC. Treatment of urinary bladder disturbances. In: Handbook of prescribing medications for elderly patients. Boston: Little, Brown and Co.; 1992. p. 313-23.
MARY E. DASH, RN, GNP, MSN, is clinical manager of the department of geriatrics at Southwest Medical Associates in Las Vegas, Nevada. EMERALD B. FOSTER, PharmD, CGP, is manager of geriatric pharmacy services, DIANE M. SMITH, RN, BS, is vice president of care coordination, and STEVEN L. PHILLIPS, MD, CMD, is medical director of Senior Dimensions Extended Care, all at Sierra Health Services, Inc./Health Plan of Nevada in Las Vegas. Acknowledgments The authors acknowledge the assistance of Aurelio J. Muyot, MD, Sherry Coffman, APN, and Debra Fulfer, RN, and thank Joann Phillips for manuscript preparation. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2003.10.021
87
CE
Contact hours: 1 Minimum passing score: 70% Test processing fee: $9 Test ID: GN0404
1. Urinary incontinence affects: A. Mostly men B. Mostly women C. Only the elderly D. Only those with dementia
7. The success of this program rests with: A. Identifying the right population B. Patient education C. Thorough nutritional analysis D. The use of new medications
2. Coughing or sneezing that causes a small amount of urine to leak is identified as: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence
Match the following medication with their resulting symptoms:
3. When a person cannot remove their clothing quickly enough to sit on the toilet in time, this type of incontinence is referred to as: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence 4. Difficulty in urinating or post-voiding dribbling is referred to as: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence 5. Nocturia, enuresis and moderate or large amounts of urine loss is called: A. Overflow incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence 6. The clinic team described in this article is comprised of all the following specialties except: A. Case manager B. Social worker C. Pharmacist D. Urologist
88
8. anticholinergics A. stress incontinence B. functional incontinence C. overflow incontinence D. urge incontinence 9. alpha adrenergic blockers A. stress incontinence B. functional incontinence C. overflow incontinence D. urge incontinence 10. alcohol A. stress incontinence B. functional incontinence C. overflow incontinence D. urge incontinence 11. Which medication is NOT listed as causing overflow incontinence: A. Psychopharmacologics B. Calcium channel blockers C. Anticholinergics D. Muscle relaxants 12. Detrusor overactivity is associated with: A. Urge incontinence B. Stress incontinence C. Urge incontinence D. Outlet obstruction
Geriatric Nursing
Volume 25
Number 2
CE ANSWER/ENROLLMENT FORM To receive continuing education credit for any test in this issue, simply do the following: 1. Read the article. 2. Take the test for the article and record your answers on the form below. (You may make copies of the answer form.) You should complete one answer form for EACH test. 3. Mail the completed answer/enrollment form along with a check or money order. Payment must be included for your examination to be processed. 4. The deadline for submitting your answer/enrollment form is 2 years from the date of this issue. 5. Your results will be sent within 4 weeks after your answer form is received. Enrollees who have a passing score will receive a certificate. Instructions: Mark your answers clearly by placing an “x” in the box next to the correct answer. This is a standard form; use only the number of spaces required for the test you are taking. Test I.D. No. 1.
❑A ❑B ❑C ❑D
11. ❑ A ❑B ❑C ❑D
2.
❑A ❑B ❑C ❑D
12. ❑ A ❑B ❑C ❑D
3.
❑A ❑B ❑C ❑D
13. ❑ A ❑B ❑C ❑D
4.
❑A ❑B ❑C ❑D
14. ❑ A ❑B ❑C ❑D
5.
❑A ❑B ❑C ❑D
15. ❑ A ❑B ❑C ❑D
6.
❑A ❑B ❑C ❑D
16. ❑ A ❑B ❑C ❑D
Name
7.
❑A ❑B ❑C ❑D
17. ❑ A ❑B ❑C ❑D
8.
❑A ❑B ❑C ❑D
18. ❑ A ❑B ❑C ❑D
9.
❑A ❑B ❑C ❑D
10. ❑ A ❑B ❑C ❑D
19. ❑ A ❑B ❑C ❑D
20. ❑ A ❑B ❑C ❑D
Credentials
Address
City
ZIP
State
Social Security No.
Phone Mail to:
License: State/No. Elsevier Attn: Gina Clites 11830 Westline Industrial Drive St. Louis, MO 63146 For more information call: (800) 325-4177, ext. 4810
Mosby Continuing Education and Training (CET) is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC-COA). This approval is reciprocal in all states and for all speciality organizations that recognize the ANCC approval process. Mosby CET is also a certified provider of nursing continuing education in California (Provider No. CEP03257).
PROGRAM EVALUATION
Strongly agree Strongly Disagree 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— 1— 2— 3— 4— 5— Easy Difficult How long did this program take to complete? hours ❑ I have enclosed an additional $10 for rush processing.
The objectives of the program were met. The content was appropriate. My expectations have been met. This form of CE is worthwhile. The level of difficulty of this test was:
❑ I have enclosed an additional $15 for foreign delivery.
March/April 2004
89