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 Incontinence: It takes a Team

In order for a treatment to work, everyone must be on the same page, from nursing and physicians to rehab and dining.

 

Residents entering a nursing facility or assisted living community may have just experienced an onset of incontinence due to a change in health condition, or they may have longstanding incontinence that is being managed on a regular basis.

Urinary and fecal incontinence are prevalent in long term and post-acute care settings, with public sources citing between 40 and 60 percent of long term/post-acute care centers’ populations being affected.

While the types and management techniques of incontinence vary, treatment is often a strategic process that involves a solid understanding of the resident’s goals, an ongoing interdisciplinary approach with the resident’s care team at the facility and their own team of family and friends, and a shared desire to see progress and treatment through to the end of a resident’s stay and beyond.

Categorizing Incontinence

Vetter Health Services, headquartered in Elkhorn, Neb., takes a restorative approach to bowel and bladder retraining. When new residents walk in the door, staff assess them for incontinence and take it a step further to determine the type of incontinence they have.

“This can fall into one of four categories—stress, urge, transient, and functional,” says Michelle Wallace, RN-BC, a certified registered rehabilitation nurse and clinical coordinator at Vetter. One of four clinical coordinators for Vetter, she has overseen operations regionally for the past six years and has a self-described passion for restorative care.

Vetter’s breakdown of the types of incontinence follows:
Stress: Incontinence related to the weakening of the muscle structure. Sneezing, coughing, standing up, any kind of movement can cause a leakage.
Urge: Incontinence brought on by irritation of the urinary system. Stimulants come into play, and serious urgency is related to it. When a resident needs to go, they need to go immediately. 
Transient: Incontinence of a reversable type. The resident may have a urinary tract infection, or they are on a type of medication, something that is typically reversible. Once the particular issue is addressed, continence is restored.
Functional: Incontinence related to a functional limitation either with the resident’s ability to move or things in their environment that functionally inhibit them from being continent.

Mixed incontinence could be a combination of any of the four types. Residents are assessed on admission, on a quarterly basis, and any time there is a significant change.

While Wallace does not base the restorative approach on a particular set of guidelines for incontinence, she follows  regulations and best practices to help inform Vetter’s unique process. She is also a member of the Association of Rehabilitation Nurses and continues to study literature on the topic.

Getting a specific sense of the type of incontinence a resident has helps define their treatment, Wallace says. “The interventions or restorative exercises we use to treat them are very different based on the type,” she says.

A Restorative Approach

Following dual goals of restorative nursing—to improve a resident’s overall functioning so they go from one level to a higher level, and to maintain progress to prevent decline from happening—nurses at Vetter focus on the resident’s potential for success to achieve goals identified with the residents. 

“For example, when we’re talking about incontinence, a lot of those goals will be more related to we’re trying to eliminate a particular time of incontinence,” says Wallace. “So if a resident is incontinent at 2:00 p.m. and they want to address that, we’ll probably focus on toileting before then at 11:30 a.m.”

Solving the Puzzle Together

Assessment and treatment originate with the nursing department and while the care plan is being developed, and interdisciplinary involvement is key. 

“Everybody brings a piece of the puzzle to make the entire picture work,” says Wallace. Life enrichment may do group exercise programming in conjunction with a restorative assistant.

“They have a large piece of that puzzle because they help with food and fluids that may help with a resident’s training program, like more fiber,” says Wallace. Social services may also help by arranging for families to bring in certain types of clothing for the resident if clothing has been found to be an issue.

Vetter’s assessment for incontinence has a lot of different symptoms, and when the symptoms are factored into the assessment, staff can categorize them and then determine the type of incontinence.

Once that happens, other parts of the puzzle become clearer. “So for instance once we know a resident has functional incontinence, we know there’s some kind of physical type of barrier,” says Wallace.

A closer look at the type of clothing the resident uses may be revealing. “Maybe it’s a range-of-motion program to help them fit their clothing easier,” says Wallace. “We’re in the Midwest, and we still have farmers that wear bib overalls. Maybe that’s not the best thing for them right now until we get that bladder working again.”

Staff will also study the resident’s mobility and their ability to use the toilet. Questions that follow could focus on the need to rearrange the resident’s bathroom or provide adaptive equipment so that they can use the bathroom.

Treatment options

For a newly admitted resident at Vetter, treatment always starts with the assessment. Once again, the type informs next steps. “Let’s say we determine it’s urgent incontinence because of an overactive bladder,” says Wallace. “We really try to drill down and see if there are certain medications that they’re taking that may be causing this. Are there other irritants like caffeine that might be causing it? We take that all into account.”  

With any resident with incontinence, staff keep a three-day bowel and bladder diary and focus on the kind or kinds of incontinence the resident experiences. Staff look to see if the incontinence happens at a particular time of day. Also, it can be drilled down further to whether or not the resident drinks two cups of coffee with their lunch, for example, and then all of a sudden can’t control his bladder because it is irritated.

For residents coming to Vetter from the hospital, staff delay starting the diary to get a more accurate picture.

“When [patients] are in the hospital, the first thing they do is put an IV in the patient, and they get abnormal fluids volume,” says Wallace. “So we give the kidneys a few days to kind of clear that before we start the diary.”

Finding Importance

A completed diary helps to structure the resident’s restorative program. And there are differences for residents who have longstanding incontinence versus those just starting. After completing a diary for a resident who has had incontinence for a long time, staff may take a more strategic approach and find things to try to influence. Finding out what’s important to the resident makes the difference, Wallace says.
“Like if there are things that the resident wants to do or places they want to go, we want to know that and focus on it so we can get that bladder to work with them for that particular time,” she says.

Another thing is it’s best to focus on small things first. Wallace encourages her restorative nurses to not set up a multi-level goal, rather to get the resident involved and see what’s most important to them.
“Let’s say the resident gets embarrassed because they’re incontinent at lunch,” she says. “Let’s focus on that first.” The nurse may solve that problem by having the resident use the toilet at a set hour before lunchtime. If that strategy works, it allows the resident to, first, feel success, and second, get a valuable experience. “Either we wake that bladder up or they really see the benefit of what they do or don’t have to go through,” Wallace says.

Old Versus New

Karl Steinberg, MD, CMD, is chief medical officer for Mariner Health Care and vice president of AMDA – The Society for Post-Acute and Long-Term Care. He says the technology has been moderately successful for incontinence in his experience, and while it is still considered new by many providers in the sector, the skilled nursing community is not always quick to adopt new things. 

Traditional methods of managing incontinence still hold much promise.

“I still think sort of old-fashioned benefits that have to do with just getting people to the toilet more often are critical,” he says. These days, a lot of the incontinence has to do with the fact that people have dementia, and they’re not remembering to go to the bathroom. “It’s back to basics, but it’s more successful than other stuff we have done,” he says.

There are different options with physical therapy. “The old standby routines like bladder training and Kegel exercises with physical therapy can help people. There’s also some other types of stimulation that can be done down in the perineal area, that generally physical therapists might be able to do in facilities if they have the training, so those types of things can be really helpful.”
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Watching Out

One of the most important things to consider is a lot of the medicines that are used for incontinence or overactive bladder are anticho­linergic drugs that can do a lot more harm than good, says Steinberg. 

“They often have a high propensity to cause delirium, heart rate issues, severe dry mouth, and urinary retention,” he says. “As a geriatrician, we always believe less is more when it comes to meds, and I’ve seen some disasters that happen from incontinence-related meds. Don’t just go to the hot new thing you saw on TV for overactive bladder.”

Urine studies are also usually not helpful to patient outcomes either, he says. “We see a lot of docs and physi­cians ordering urine studies, and then you wind up with a culture growing such as 100,00 colonies of E. coli. And then they wind up getting completely unnecessary treatment for what isn’t a urinary tract infection [UTI], but rather a colonized bladder that is not causing any problems.”

Doing more harm than good comes from the fact that the resident is not having UTI symptoms, and incontinence alone is not a reason to get a urine study, he says.

Or if a resident does get the study and grows 100,000 colonies of bacteria, the bacteria are probably not what’s the problem. “A UTI is not single-symptom, and nowadays with the McGeer critieria or the Loeb criteria it requires more symptoms,” he says. This is especially true in someone who doesn’t have dementia; a UTI diagnosis usually requires three signs or symptoms.  

Bladder Scanners

If patients are having overflow incontinence because of a bladder outlet obstruction, it can be a serious problem because it can wind up backing up into the patient’s kidneys, and they can wind up with kidney failure, for example. Here, bladder scanners may help.

“In this day and age, at least in my area, quite a few facilities have bladder scanners, and that’s a really useful tool to rule out or confirm any kind of bladder outlet obstruction,” Steinberg says. “Right after someone urinates, you go and you put the ultrasound on them. If they still have quite a bit of urine in the bladder, you know they’re not fully emptying, and that’s something where they may be able to get a urethral dilation or other intervention.” If a provider becomes aware that a patient is retaining urine, that becomes a potentially serious problem. Along those same lines, bowel-related problems should also be ruled out. “As people get constipated, they basically have a ball of stool there right in the sigmoid colon or in the rectum and that’s pushing against the bladder outlet, and [urine] can’t get out of the bladder,” says Steinberg. “So those are things that people should keep in mind.”

Working with Stigma

Seeking the help of residents who are able to speak on their own behalf to share the details of their incontinence depends a lot on their level of comfort in talking about the issue openly. Providers can help by making sure the conversation gets started on the right track by normalizing it early on.  

“I think usually one of the nice ways of bringing it up is saying, ‘Hey, a lot of people I look after have some problems with urinary incontinence,’” says Steinberg.

This is similar to end-of-life discussions. “Similarly, we have these end-of-life discussions and say, ‘I’m not suggesting that your heart’s about to stop any day now, but we talk to everybody about this, and it’s not meant to scare you,’” he says. “It’s just because we think it’s important to address, and there may be something we can do about it.”

This often gets the conversation rolling, he says. “I think kind of normalizing the conversation in my experience, by the time that someone is in a nursing home, it’s probably going to be less of an issue than if you’re sort of a ‘walkie-talkie,’ community dwelling 60-year-old,” he says.

Wallace sees progress being made. “I think we’re finally starting to turn the corner a little bit that it’s normal for people to be incontinent at times as they age,” she says. It’s also becoming more public, with ads on TV, which also opens the path to more open conversations about incontinence with residents.

“Ultimately these conversations are part of our assessment,” she says. “When a resident comes in, we put a foot in the door when starting to talk about incontinence. I think, again, part of it is really finding out what the value is to that resident. For someone that’s been incontinent for a long time and is managing it, it’s not much of a stigma issue versus for someone that recently had a procedure done and this may be a new development.”

Making it Work

To really make things work, Wallace again emphasizes finding out the resident’s goals early on. “If a resident is not even buying into trying to rehabilitate his bladder, you’re banging your head against the wall,” she says. “But if he is really excited and involved, it means a lot to combine your efforts and not work against each other.” 

One of the most important pieces of advice for making a big team effort like incontinence treatment work is that staff throughout the facility need to give a consistent message, says Wallace. “If not everyone is on the same page and we’re not consistently all working with that resident in the same way, it can really be detrimental to your progress,” she says. This includes keeping everyone in the loop, including the resident’s family and friends in those discussions, with the resident’s permission. “The more people we educate, the better everybody understands what the goals may be and how they can help,” she says.
Another piece of advice is to involve certified nurse assistants (CNAs) from the beginning as staff start to discuss developing a care plan for the resident. 

“CNAs can contribute huge input,” says Wallace. “Like, ‘The resident always transfers better from this side,’ or ‘She likes to do morning devotions at 8 o’clock.’ Involving CNAs shows that they know what they are talking about and have real input into the whole system.”

A Critical Piece

Maureen McCarthy has been a registered nurse for over 30 years with experience as a Minimum Data Set (MDS) coordinator, director of nursing, and rehab director. She is president of Celtic Consulting and advises a number of clients on issues such as incontinence. Involving CNAs in every step of incontinence care is critical to success, she agrees. 

“There is a tendency at times to not treat CNAs as nursing assistants, but as caregivers,” she says. “And they need to be advanced to that nursing assistant level so they can really help the nurse out on the unit.” 
A way to do this is to keep the CNA informed of changes and developments in the resident’s care plan. This is critical as CNAs are often the first to notice if a resident has an incontinent episode.

“If we change something on the assignment or we have a Section GG goal that a resident is going to toilet themselves independently, we make sure to tell rehab and nursing and our physicians, but we also need to make sure we tell the person who is doing the hands-on care, and that’s the CNA.”

Often centers will have CNA assignment cards or care cards, but these are not always effective because there’s an expectation that everyone will read them, says McCarthy. “Really all it is is a piece of paper, and it’s almost like Where’s Waldo. That shouldn’t be the only outlet to share what has changed with a resident,” she says.

Everyone on the team, including the CNA, should also be receiving verbal communication about the resident’s goals for discharge and any changes that need to be made, she says.
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Stepping Back

Another aspect of CNA involvement to boost and reach resident outcomes has to do with holding back and letting the resident take the reins. “We need to let the patient perform and have the CNA assist them,” says McCarthy. Oftentimes, she says, the CNA is performing activities of daily living for the resident instead of assisting them, but this works against the patient’s progress. 

McCarthy recalls one provider that had a rehospitalization rate of 30 percent. So her team went back over the discharges over the past three months of the 120-bed facility that only had six long term care patients. After reviewing responses to questions from three months of short-term patients and residents, it was found that 85 percent of them said they had no idea how much help they were getting from the CNA until they went home alone.

“We should be letting the residents perform more of the ADLs [activities of daily living] on their own if they’re going to be going home,” says McCarthy. “That helps the patient better prepare because we assist them instead of doing it for them, and this leads to a better outcome at home later.”

Dealing with Dual Issues

Wallace recalls one resident who had recently had a stroke. The care team was not only dealing with his incontinence but with his post-stroke depression. “His lot in life had changed, and so really helping him to work through that was key, [and] the interdisciplinary involvement all helped,” she says: life enrichment to help fill his day and social services to help focus on his psychosocial needs. 

After talking with the resident, staff learned that his morning activity was hugely important to him, so they decided to focus on that time of day—9:00 a.m.—so that he was not incontinent during that time. Staff acted accordingly and worked to consistently toilet the resident at 8:45 a.m. 

After some time, the resident began to get more functional as things went on throughout the day, and his overall continence started evolving. “By focusing on that one particular time, I think it really helped wake his bladder up, but it also helped him to gain some success and momentum.” Eventually, the resident was able to restore his continence and went home. 

“So sometimes it’s those little things,” says Wallace. “It’s trying to not knock it out of the ballpark the first time you’re up, but instead focusing on a small piece of the puzzle.”

A Better Outcome

McCarthy says her clients have seen success with bowel and bladder programs, and it is rewarding. One such instance had to do with a younger patient in her late 40s who was toward the end of her life with a cancer diagnosis. She had young children and did not want to stay in the nursing center; she wanted to rehab to be able to go back home to be with her family. “Getting this patient to get her strength back and the bladder toned to be able to be continent so she could be able to go home and die the way that she wanted to with her dignity was huge for us,” says McCarthy. 

When she was discharged from the hospital, it was known that she had a terminal diagnosis, and the physician also knew that she would not get rehabilitation if she came into the nursing center under hospice, so he documented, highlighted, and underlined that she was not end-stage, not a candidate for hospice.

“The physician wanted her to get the rehab because that’s what the patient wanted,” says McCarthy. The state surveyor cited the facility for not coding the patient for being on hospice and not having an end-of-life condition when it clearly went against the documentation.

“We went to IDR [informal dispute resolution] and won it,” says McCarthy. The patient ended up getting the rehab and was able to go home and be with her family as she had wished.

“That’s how far you have to fight to get what you need for a patient,” says McCarthy. “It’s all about the patient.” ■
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