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Continence Promotion in Care Homes

Continence Promotion

Prevalence and Cost of Incontinence

Historically it is challenging to obtain accurate statistics around the prevalence of incontinence; due to the stigma associated with the condition, people have tended to suffer in silence due to feelings of embarrassment or shame.

However, it is thought that around one in four people will suffer from a degree of urinary incontinence during their lifetime. Women are more commonly affected than men due to childbirth and menopause.

Men are more likely to experience problems with retention as they age due to enlarged prostates.

One in ten people will experience a bowel problem at some point in their lives. For people living in care, up to two thirds will suffer from incontinence.

Two thirds of people in care

 

Types of Incontinence

Stress Incontinence

Stress incontinence is the most common type of incontinence. 

This occurs when the pressure in the bladder is too great for it to withstand. The pelvic floor muscles are responsible for maintaining bladder control and when they become weak stress incontinence can occur.

Symptoms present as leaking urine when pressure is applied to the abdomen, such as during coughing, sneezing, laughing or exercising.

The most common cause for weakened pelvic floor muscles is childbirth, but the cause can also be attributed to obesity, menopause and increasing age. 

Stress incontinence can also occur in men who have received treatment for prostate cancer.

Treatment for stress incontinence includes:
  • Pelvic floor exercises
  • Referral to a specially trained physiotherapist
  • Surgery is used as a last resort if other methods do not help

 

Urge Incontinence (also known as Overactive Bladder) 

Urge incontinence is the second most common type of incontinence.

Someone with an overactive bladder will have a sudden urge to pass urine and will need to go to toilet frequently. They are likely to need to get up and use the toilet more than once during the night. If a toilet is not immediately available, then incontinence may occur. 

The bladder muscle contracting too early causes this incontinence, where normal control becomes reduced. 

Urge incontinence is common when people suffer from neurological disorders such as Parkinson's disease, multiple sclerosis, after a stroke or in spinal injuries. 

Treatment for urge incontinence includes:
  • Bladder retraining 
  • Adjusting fluid type, and intake, can relieve symptoms. Note however, that this is not simply about drinking less, as this can further irritate the bladder (urine will be more concentrated thus causing the severity of symptoms to increase)
  • Medication to relax the bladder

 

Mixed Incontinence 

A mixture of stress and urge incontinence results in mixed incontinence. 

Some people do suffer with both types of incontinence simultaneously. 

 

Outflow Obstruction

The most common cause for this is an enlarged prostate gland.

Outflow obstruction is caused by a blockage of the urethra and this makes it difficult to pass urine. 

The symptoms are frequency, urgency, hesitancy, straining, waking in the night to use the toilet and dribbling after micturition. 

Apart from an enlarged prostate, this can also be caused by constipation, as a full rectum can apply enough pressure to block the urethra.

Treatment for outflow obstruction includes:
  • Medication to relax the bladder neck
  • Relieve and manage constipation
  • Dilation of the urethra
  • Surgery to prostate

 

Functional Incontinence

Functional incontinence is an inability to reach the toilet due to poor physical or mental health.

This is more common in the elderly due to causes such as dementia, poor mobility, poor manual dexterity, and visual problems.

There are also environmental factors, for example short staffing in a care home meaning that there is no one to take a person to the toilet in time. For a person at home who relied on visiting carers, if they are late then this may have caused them to become incontinent.

Treatment for functional incontinence includes:
  • Practical steps such as easy access to clothing, moving furniture or mobility aids can all help someone to be more able to access the toilet and remain independent
  • A thorough assessment of the issues must take place and carers can start to find ways to help address the problems

 

Bowel Care

A healthy bowel pattern is going to the toilet anywhere between three times per day and three times per week. Everyone is different and anything on this spectrum is considered normal.

Going to the toilet should not cause pain and bowel movements should be easily passed. 

Healthy bowel patterns

Problems that people have with their bowels that can cause incontinence include:

Constipation

In the elderly, constipation and faecal impaction are common causes of incontinence.

Overflow Diarrhoea

Occurs when people are so constipated that their bowel is full of hard faeces. The liquid stools higher up in the bowel are able to pass past the hard mass and causes the person to have diarrhoea. This can be dangerous as people may not realise that there is an issue with constipation and believe the opposite to be true.

Medical Conditions  

Conditions such as Irritable bowel syndrome, Crohns and Diverticular disease can cause problems with a person's bowels. Also, conditions that affect the nervous system, such as Multiple Sclerosis, Diabetes and Stroke.

Bowel Surgery

Surgery to the bowel may result in long-term changes to normal defecation.

 

Causes of Constipation

In the elderly, constipation is a common problem. It is estimated that one in seven adults in the UK suffer from constipation. In the older generation, it is likely to be far higher.

1 in 7 Adults

Nutrition and Hydration

Lack of fibre, not eating enough and inadequate fluid intake can all contribute to constipation.

Poor Mobility

In the elderly, a lack of movement can cause a person to become constipated. Also, being unable to sit on a toilet and get into the correct position to have their bowels open causes problems. 

Psychological 

In care homes, having to open their bowels in front of carers can make it difficult for a person to go. The environment should be as private as possible and carers must ensure that dignity is upheld and try to encourage their residents to be at ease.

Medication

Some medicines can cause constipation. Most commonly painkillers, particularly codeine and other opioids. Other medicines such as calcium supplements and anti-depressant medication can also have this effect.

 

Managing Incontinence in Care Homes 

Every person with incontinence should have a full holistic continence assessment to fully understand his or her issues and the impact that they are having on their day-to-day life.

Care homes should have policies in place that focus on promoting continence and condemn institutionalised care such as toileting timetables.

Carers should assess and evaluate their resident's continence needs and follow the advice given at continence assessments to ensure that the correct products and techniques are used.

Indwelling urinary catheters should be a last resort and should not be inserted solely to manage urinary incontinence. Urine infections are the most common type of infection in care homes and if a person has an indwelling catheter, they have a much higher risk of infection.

Maintaining a high standard of hygiene is vital for people living with incontinence. Skin can quickly break down if urine and faeces is in contact with the skin for any length of time. Furthermore, hygiene should be at the forefront of carer's minds in order to uphold their resident's dignity.

Managing constipation can reduce the likelihood of faecal incontinence.

Promotion of good nutrition and hydration can help improve incontinence.

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