Evidence-based care approaches for urinary incontinence in older adults

¶ … Evidence-Based Care for Urinary Incontinence in Older Adults

The percentage of older adults is increasing in many countries of the world, including the United States in particular. As the so-called Baby Boomer generation reaches retirement age, more and more of these older adults will likely experience a number of age-related problems. Although urinary incontinence is not an age-related condition nor is it a disease, older adults tend to suffer from the types of physical, environmental and psychological conditions as well as various pharmacological treatments that increase its incidence in this segment of the population. To identify a set of best practices based on evidence-based care for urinary incontinence in older adults, this paper provides a review of the relevant juried and scholarly literature, followed by a summary of the research and important findings in the conclusion.

Literature Review

While the condition is commonplace, there are some important issues involved in the treatment of urinary incontinence among older adults that healthcare providers must take into account when formulating treatment plans for this segment of the population. For instance, according to Ebersole and Hess (1999), "Urinary incontinence is one of the most prevalent symptoms encountered in the care of the aged. Many families cannot cope with incontinent relatives. It is therefore not surprising that incontinence is judged to be the second leading precipitating cause of institutionalization of the aged" (p. 288). The prevalence of urinary incontinence among older adults is fairly significant, with estimates ranging between 15% and 35% for the approximately 30 million older adults in the United States (Ebersole & Hess, 1999). Moreover, the prevalence increases to more than half (53%) for older adults who live in nursing homes, representing about one-and-a-half million older adults, a figure that is expected to increase as this segment of the population increases as a percentage of the larger population (Ebersole & Hess, 1999). An operationalization of the term urinary incontinence is provided by Fantl, Newman and Colling and their associaters (1996) who note that this condition is an "involuntary loss of urine that is sufficient to be a problem" (p. 288).

Significantly, Ebersole and Hess emphasize that, "Incontinence is not a result of advancing age, nor is it a disease. It is a symptom of existing environmental, psychologic, drug, or physical disturbances and can become a catastrophic event when it interferes with mobility, sociability, and the ability to remain in one's home" (1999, p. 288). This point is also made by Burke and Laramie (2000) who note, "Urinary incontinence, the involuntary loss of urine, is a significant health problem -- not a normal consequence of aging" (p. 509). Unfortunately, many older adults and believe that urinary incontinence is simply part of the aging process and fail to seek treatment (Ebersole & Hess, 1999). The same misperceptions about urinary incontinence extend to the healthcare community as well. For example, Strange (1999) emphasizes that, "When it is discussed, all too often, patients are told--incorrectly -- that it's a normal consequence of aging and that they should just get used to it. Misconceptions about incontinence abound among health-care professionals and the public alike" (p. 28). Consequently, when older adults and their healthcare providers both believe that the condition is a normal part of the aging process, they may fail to seek treatment for the condition, making the outcome a self-fulfilling prophecy (Ebersole & Hess, 1999).

The known risk factors for older adults that are associated with urinary incontinence include the following:

1. Immobility of chronic degenerative diseases;

2. Diminished cognitive status, dementia;

3. Delirium;

4. Medications including diuretics;

5. Smoking;

6. Fecal impaction;

7. Low fluid intake;

8. Environmental barriers;

9. High-impact physical exercise;

10. Diabetes;

11. Stroke;

12. Estrogen deficiency; and,

13. Pelvic muscle weakness (Ebersole & Hess, 1999, p. 288).

The most common types of urinary incontinence in older adults as stress incontinence (which can result from inadequate closure of the sphincters between the urethra and bladder), urge incontinence (which can be caused by a hyperactive bladder musculature) (Schultz, Noelker, Rockwood & Sprott, 2006), overflow incontinence (which can be caused by neurologic abnormalities of the spinal cord affecting the contractility of the detrusor muscle of the bladder), iatrogenic (which can be caused by side effects from medications) and functional (which can be caused by musculo-skeletal disability or severe cognitive impairment) (Ebersole & Hess, 1999) and these various types of urinary incontinence are described further at Appendix A. It is also important to note that older adults can suffer from more than one type of urinary incontinence problem at the same time, a condition termed "mixed incontinence" (Ebersole & Hess, 1999, p. 289).

Although it is not a "normal" part of the aging process, older adults tend to be at higher risk for urinary incontinence because of several factors. For instance, Strange emphasizes that, "Incontinence is never normal at any age. Age-related changes in the lower urinary tract may make older people more likely to experience incontinence" (p. 29). According to Mezey, Fulmer and Abraham (2006), "Age-related changes including a decrease in bladder capacity, benign prostatic hyperplasia in men and menopausal loss of estrogen in women can affect urinary tract function and predispose individuals to urinary incontinence" (p. 85). Likewise, older adults are also at increased risk of experiencing the negative consequences of alcohol use more acutely by consuming more than the generally recommended safe upper limits and a number of comorbidities are associated with this practice including urinary incontinence (Pachana, 1999). In addition, older adults who are homebound and who suffer from urinary incontinence are at increased risk of depression (Proctor, 2008). Besides depression, diminished self-esteem and the social anxiety that can result from urinary incontinence in older adults, there are some significant other adverse healthcare outcomes that can result when the condition remains untreated. In this regard, Burke and Laramie report that, "Physically, urinary incontinence can cause skin breakdown, lead to recurrent urinary tract infections, and inhibit the healing of any existing skin conditions" (p. 509).

There are also some constraints involved in treating older adults for urinary incontinence that must be taken into account by the healthcare practitioner. For instance, Pachana (1999) notes that, "Older adults may experience several barriers to treatment. For example, therapists should be sensitive to the presence in older patients of sensory deficits, such as impaired vision or hearing, or cognitive impairments, which may have a negative impact on the therapeutic process if not taken into account" (p. 107). This author also cites other factors such as a lack of transportation and financial constraints that have the potential for preventing many older adults from actively seeking treatment for urinary incontinence (Pachana, 1999).

Conclusion

The research showed that urinary incontinence is a common condition among older adults, currently affecting millions of Americans with more expected as the Baby Boomer generation reaches retirement age and experiences the age-related maladies that can contribute to the incidence of the condition. The research was absolutely consistent, though, in emphasizing that urinary incontinence is not an age-related disorder nor is it a disease, but rather older adults tend to suffer from a wide range of aging processes that predispose them to the condition. Because there remains a fundamental lack of understanding among many older adults and healthcare providers alike concerning these issues, the research was also consistent in stressing the need for clinicians to more fully understand the causes of urinary incontinence and the treatments that are available. The condition was shown to be the second-most common cause of older adults being institutionalized because of the inordinately demanding nature of caring for them that is typically beyond the ability of many spouses or other family members. In the final analysis, the chances of older adults suffering from urinary incontinence are fairly high given that the population will increasingly include older adults, many of whom will be among the very old.