Treatment of Urinary Incontinence with Clients that Have Cognitive Impairment

1. Treatment of Urinary Incontinence with Clients that Have Cognitive Impairment

2. Learning Objectives • Define the different types of UI and the implications for patients with cognitive impairment • Describe the assessment process for clients with UI that have dementia or other types of cognitive deficits • Articulate various treatment strategies to reduce UI for geriatric clients that have cognitive impairments.

3. Urinary Incontinence • UI Overview • Types of Incontinence • Patient Identification • Evaluation • Treatment

4. Why is it important to impact UI? • Reduced incontinence can reduce frequency of skin breakdown, UTI’s, urosepsis and falls. • Reduced incontinence improves well being, dignity, independence and participation in activities.

5. Prevalence • UI affects 25 million Americans (National Association for Continence, 2004) • UI affects 65% of nursing home residents (Ostomy Wound Management, Diane Newman, 12/2006) • Estimated cost of $19.5 billion in the US (Wagner and Hu 2000). • Estimated cost based on Aegis/Golden Living figures per incontinence episode- $10.00 (includes labor, laundering and continence management products)

6. The issues • Physical and emotional well being is affected. • Increased risk for falls • Do we passively encourage UI because we automatically accept it in our population? • Embarrassment • ADL limitations • Reduced socialization • Depression • Increased burden of care • Skin integrity

7. What is Urinary Continence? Continence - controlling the flow of urine and preventing the unexpected loss of this control. • Bladder fills, the sphincter muscles tighten, the pelvic floor is elevated, urine is retained • If bladder is ~ ½ full, healthy individuals can suppress this urge.

8. What is Urinary Continence? Voiding – heavy autonomic n.s. involvement • bladder fills – stretch receptors activated • brain releases inhibitory control  micturition reflex – • detrusor contraction • relaxation of the smooth mm. of the sphincters • relaxation of the pelvic floor mm. • voiding occurs

9. What is incontinence? • It’s not a disease, but a symptom of other conditions. • It can be managed or cured- even in clients with cognitive impairment. • Age related changes make the elderly more vulnerable. UI is not a normal consequence of aging. However age related changes in the urinary tract do predispose the older person to incontinence.

10. Types of Urinary Incontinence Continence: To remain continent, the bladder must be able to store increasing amounts of urine under low pressure. During normal urination the muscle lining the bladder walls develops a sustained contraction in coordination with relaxation of the sphincters allowing urine to flow. UI is not a normal consequence of aging. However, age-related changes in the urinary tract do predispose the older person to incontinence.

11. Types of UI (continued) • Urge incontinence is the loss of urine shortly after feeling the need to void. • There may be a sudden strong urge to void. • They are often unable to make it to the bathroom on time. • They go to the bathroom frequently and often wake up more than 2 times per night.

12. Types of UI (continued) • Stress incontinence is the loss of a small amount of urine with increased intra-abdominal pressure. • People may leak urine when they cough, laugh, sneeze, exercise, or change position. • They go to the bathroom more frequently to avoid leaks and usually sleep through the night.

13. Types of UI (continued) • Mixed incontinence is a combination of stress and urge. • This is the most common type in elderly women.

14. Types of UI (continued) • Overflow incontinence is the loss of a small amount of urine due to over-distension of the bladder. • Presents as frequent “dribbling.” • People may take a long time to urinate and have a weak dribbling stream. • They may urinate small amounts throughout the day without feeling empty.

15. Types of UI (continued) • Functional incontinence is urine loss due to factors outside of the urinary tract.

16. Types of UI (continued) • Reflex/unconscious incontinence is urine loss with no sensation of the need to void. • May cause constant dribbling or large volume.

17. Types of UI (continued) • Detrusor Hyperactivity with Impaired Bladder Contractility (DHIC) is involuntary but inefficient detrusor contractions. • People will strain to completely or incompletely empty the bladder.

18. Client/Patient Identification • Listen for and ask about continence changes during staff meetings or at intake interview. • Ask the aids, caregivers and /or activity personnel who they toilet often or find wet. • During charting, read the most recent nurse’s notes.

19. Evaluation Of Incontinence • Many residents with UI will benefit from a therapy evaluation and treatment. The results of the evaluation may indicate the need for restorative, compensatory and/or adaptive strategies based on their cognitive status.

20. Evaluation continued: • Frequency, timing and volume of loss. • Best determined through the use of a toileting or bladder diary/record. • These can be used to help assess the type of UI as well as a starting point for bladder re-training. • Examples of bladder diaries are available in this training. However, many customers have well defined means of obtaining this information and can share this with rehab staff.

21. Evaluation continued: • Questions to ask during evaluation: • Do you have urine leakage when you sneeze, laugh, stand, walk, exercise, yell etc? (This may be an indication of stress incontinence) • Do you experience an urgent need to urinate? How often do you experience an urgent need to urinate? (This may be an indication of urge incontinence)

22. Bladder Record Resident’s Name:_____________________________ Resident’s Room #:_________ Date:__________ Instructions: Place a check in the appropriate column next to the time the resident urinated in the toilet or when an incontinent episode occurred. Estimate the amount of liquid the resident drank during that time period (for example, one cup). 24 Hour Voiding Diary  Location: Bedside commode, urinal, bedpan, toilet  Fluid: Type and amount

23. ACL score 4.0-5.0 Age equivalency: 4 to 7 years Key Indicators- Needs structure and routine for increased safety and independence with toileting Assess cognitive and physical ability to use urinals,report changes in bowel and bladder pattern,follow routine, locate restroom and toileting items, adaptive equipment, bathroom etiquette Challenges of the Cognitively Impaired

24. Challenges of the Cognitively Impaired • ACL score 3.0-3.8 • Age equivalency: 18-24 months to 3 years • Key Indicator(s)-May needs cues for toileting. Needs structure and toileting routine. Limitations in visual field. Poor attention span. Will need extra time • Assess physical and cognitive ability to recognize and communicate need to toilet, don and doff clothing, completion of hygiene task, difficulty with fasteners and zippers, imitate modified technique, learn new destination of restroom, sequence toileting action

25. Challenges of the Cognitively Impaired • ACL score 1.0-2.8 • Age equivalency: 0-5 months to 12-23 months • Key Indicator(s) – Postural instability. Teach staff/caregivers to cue patient appropriately (visual, tactile, verbal) allowing 2-3x slower response time. Address safety issues. • Assess cognitive and physical ability for sensory stimulation, bed mobility with rolling and bridging, sit on toilet, stand pivot transfer, follow caregiver to restroom, communicate need to toilet, walk to familiar location, utilize grab bars, adjust garment, wiping for hygiene

26. Dietary Bladder Irritants • Assess impact of bladder irritants • Alcohol • Caffeine • Tomato based products • Highly spiced foods • Artificial sweeteners • Citrus and fruit juice

27. Treatment Approximately 80% of those who suffer from UI can significantly improve or cure their incontinence with behavioral therapies and pelvic muscle rehabilitation.

28. Treatment • The federal Agency for Health Care Policy and Research (AHCPR) has published specific guidelines for the treatment of incontinence • AHCPR states - “the first line of treatment should be the least invasive with the fewest potential adverse reactions or complications” and that “for many forms of urinary incontinence (UI), behavioral methods meet this criteria”

29. Treatment • Schedule or Habit training • Prompted voiding • Bladder re-training • Relaxation training / body quieting • Clothing adaptations / modifications • Environmental changes • Dietary management: bladder irritatants • Bladder diary • Compensatory strategies for the cognitively impaired • Pelvic muscle exercises • E-stim and biofeedback

30. Treatment Scheduled Voiding (used to address urge, stress, mixed and functional incontinence) - • “Scheduled toileting” • implemented to match a patient’s voiding habits • caregivers assist resident to the toilet during times of greatest voiding frequency • toileting schedule determined by voiding diary • not used to increase time between voids • not used to teach residents to resist the urge to urinate

31. Treatment Bladder Re-training (used to address urge, stress, and mixed incontinence) – • Usually initiated by therapy • Generally consists of three primary components - • education • scheduled voiding • systemic delay of voiding (with positive reinforcement) • Resident required to postpone voiding and urinate according to a timetable rather than according to the urge to urinate • The resident must be able to follow simple directions to be successful with this type of program.

32. Treatment Prompted Voiding (used to address functional incontinence) – • Can be used with residents who are cognitively impaired. • Used for residents who – • are aware of bladder fullness/need to void • can ask for assistance or respond when prompted to toilet • Also effective with the cognitively intact residents • For those who are cognitively impaired - • Combine with scheduled toileting

33. Treatment - Exercises • The purpose of pelvic muscle rehabilitation is to improve function of the pelvic floor • There are a number of therapeutic exercises and techniques that are used to strengthen the pelvic floor and associated muscles. • In addition to the pelvic muscles, the diaphragm, abdominals, back extensors, and hip musculature also play a role in maintaining continence. • Referred to nursing for carryover as appropriate

34. Treatment - Exercises 1. Pelvic floor strengthening – • Contract as if trying to stop the flow of urine. • Easiest done in a seated position. Can progress to standing. • don’t “bear down” • Instruct the resident to continue breathing through out. • progress to 10 second holds (over time) • 10 to 20 second rest periods between contractions • Progress to 10 repetitions 2-3 times per day.

35. Treatment - Exercises 2. Abdominal strengthening exercises a. Patient supine in bent-knee position – slowly lift and lower head and shoulders off of bed/mat b. Pelvic tilts 3. Diaphragm a. Rhythmic breathing b. Diaphragmatic facilitation (as needed, per Complex Disease Mgmnt) 4. Back extensors a. Back stabilization exercises b. Core stability and static balance 5. Hip muscles a. Hip abduction – theraband b. Hip adduction - theraband

36. Treatment - Exercises • Hip exercises continued: c. Internal rotation – theraband d. External rotation – theraband at ankle, start with femur internally rotated and bring foot out to the side. e. Extension – sit to/from stand f. Flexion – cuff weights

37. Treatment – Physiological Quieting: • The autonomic nervous system directs bladder function. • If the ANS is over active it can cause bladder dysfunction. • Treatment to quiet the resting level of the ANS can be an effective UI technique. • These techniques are known as physiological quieting (PQ). A. Diaphragmatic breathing B. Hand warming C. Body/Mind quieting

38. Treatment – Electrical Stimulation- overview • Medicare has ruled that e-stim for UI may not begin until 4 weeks after a “failed” trial of pelvic muscle exercises. A failed trail is defined as no clinically significant improvement. • E-stim of the pelvic floor muscles has been proven to be effective in the treatment of stress, urge and mixed incontinence. • Surface electrodes are used at low frequency to produce contractions pelvic floor. • This gentle and non-invasive treatment is well tolerated by most patients. May consider for level 3.6 with extra supervision and cues.

39. Pharmacological Considerations: • There are many medications that can create or exacerbate UI. • There are many medications used for the treatment of UI as well.

40. Treatment Dietary Education - • Reduce intake of irritants - • Alcohol • Caffeine • Tomato based products • Highly spiced foods • Artificial sweeteners • Citrus & Fruit Juice • Maintain healthy fluid intake – lesser volumes of urine are more concentrated and more irritating

41. Treatment Environmental Modifications - • Move the bed closer to the bathroom • Clear the path to the bathroom • Alter medication schedule • Manage liquid intake • Provide raised toilet seat and hand rails • Black toilet seat on white commode to accommodate perceptual changes • Keep walker in same spot for immediate access/mark the spot on the floor

42. Treatment Clothing Management • Pull on, elastic waist pants • Velcro fasteners • Properly fitting undergarments • Provide alternatives to adult briefs – use pads and panty liners • Address toilet hygiene during OT (reduce risk of UTI)

43. ACL score Abilities / Special Considerations Treatment Strategies 1.6 –1.8 With stimulation may cooperate by rolling to side or bridging. Training on optimal positioning Scheduled use of bedpan based on patient’s pattern or habits. Training on optimal positioning for toileting. 2.0 May be able to sit on toilet after placement by caregiver. May be able to assist with wiping with cues Scheduled toileting, Transfer training -Count to three. Dietary Management 2.2 May cooperate with pivot transfer to toilet. May also be able to sit or stand on command while being wiped. Same as 2.0 Elevated toilet seat. Environmental modifications as needed. Functional mobility training. Treatment Strategies for Patients with Cognitive Impairments

44. ACL score Abilities / Special Considerations Treatment Strategies 2.4 May follow caregiver to bathroom when cued. May sit and stand spontaneously with toileting Same as 2.2. Develop assisted toileting routine. Trunk flexion exercises to increase strength of pelvic floor. 2.6 May communicate the need to use toilet. May initiate voiding and assist. with toileting tasks. Same as 2.4 Development of related communications program. 2.8 May be able to walk to bathroom. May use grab bars. May adjust garments and wipe with assistance. Same as 2.6 May be able to participate in modified PME (Pelvic Muscle Exercise) program. Treatment Strategies for Patients with Cognitive Impairments

45. ACL score Abilities / Special Considerations Treatment Strategies 3.0 May recognize the need to use toilet. May get distracted on the way. May wipe ineffectively and flush toilet with cueing. Same as above. Scheduled toileting, Prompted voiding and modified PMEs including participation in PME groups. Modified garments. Environmental modifications Compensatory communication systems. Pre –tear paper to prevent excessive use. Dietary management. 3.2 Patient may be able to communicate need to use toilet. Will grasp paper and wipes back and forth without noting results. Treatment Strategies for Patients with Cognitive Impairments

46. ACL score Abilities / Special Considerations Treatment Strategies 3.4 Usually recognizes need to void. May go to familiar bathroom, don and doff clothing but may need extra time and help with fasteners. May use excessive tissue and forget to flush and wash hands. Same as above. 3.6 Patient may be able to imitate modified wiping techniques. May be able to sequence toileting action but may leave out one or two steps. Same as 3.0 and 3.4. Memory systems. Provide training on modified wiping techniques. Allow extra time to complete routine. Bladder re-training. Prompted voiding. Modified PMEs. E-stim. Treatment Strategies for Patients with Cognitive Impairments

47. ACL score Abilities / Special Considerations Treatment Strategies 3.8 May learn new destination (way to toilet). Usually able do toileting task including remove and pull up clothing, using toilet paper, flushing and washing hands with supervision . Same as 3.0 and 3.4. Memory systems. Allow extra time. Bladder re-training. Prompted voiding. Modified PMEs. E-stim.Kegels using mostly tactile, visual and verbal cues. 4.0 May initiate toileting activities at usual time of day. May have trouble with some fasteners. Will not be able to locate unfamiliar restroom.. Males may be trained to locate and use urinals Prompted voiding and modified PMEs. Environmental Modifications Compensatory memory strategies. Bladder re-training. Safety strategies, Dietary management, Modified Physiological Quieting, E-stim, Kegel exercise with cues. Treatment Strategies for Patients with Cognitive Impairments

48. ACL score Abilities / Special Considerations Treatment Strategies 4.2 Usually initiates toileting at customary time of day. Can recognize issues that interfere with toileting. May be able to be trained to report changes in bladder and bowel habits. Same as 4.0 4.4 Usually able to follow customary toileting routine. Will need to be shown the location of public restrooms. May not note errors with clothing adjustments. 4.6 Able to scan environment to obtain supplies. Able to locate sign for a public restroom. May not anticipate need to use bathroom before trips etc. Females may be able to be trained to use female urinals. Same as 4.0. Treatment Strategies for Patients with Cognitive Impairments

49. ACL score Abilities / Special Considerations Treatment Strategies 4.8 Can independently perform typical toileting routine. Able locate a public restroom. Can use portable urinals and may be able to learn to use adapted tissue aids. May be able to learn bathroom etiquette. PMEs, bladder re-training, E-stim. Environmental and dietary modifications. Physiological Quieting, Kegel exercise. May be able to complete bladder diary with assistance. Address safety issues. 5.0 – 5.8 Able to use urinals and adaptive tissue aid with less effort. May need assistance to remember safety precautions. Can locate bathroom without assist. May not anticipate need for toileting in new situation or consider sanitary requirement in unusual situations. Same as above. Will need less assistance to complete bladder diary. Bio feedback. Treatment Strategies for Patients with Cognitive Impairments

50. Discharge Planning • Discharge considerations • Discharge planning questions • Carry over plan development