Incontinence and dementia in aged care
Expert: Dr Joan Ostaszkiewicz
Joan is a registered nurse with a clinical and academic background in the management of incontinence in frail older adults. She is a Postdoctoral Research Fellow in the Centre for Quality and Patient Safety Research at Deakin University. Joan's research focuses on evidence-based nursing strategies to enhance continence care for older people with dementia and those living in residential aged care facilities.
She is widely published and her research includes Cochrane systematic reviews, guidelines, continence assessment and management tools, and more recently, a model of care for the long-term aged care sector. She recently completed her PhD which resulted in a grounded theory about providing continence care in this sector.
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This video dicusses how to best manage continence care in adults who have dementia. Dr Joan Ostaszkiewicz is a registered nurse with a clinical and academic background in the management of incontinence in frail older adults.
Q&A with Dr Joan Ostaszkiewicz
Q: I am a carer in a high care facility and I am getting mixed messages about the benefits of waking people overnight to toilet them to try and keep them dry with variable success. The residents who are confused also have trouble going back to sleep again and then want to wander. What is the right answer to overnight toileting?
A: There is much confusion and debate about the best approach to managing incontinence at night in aged care homes. The reason for this confusion is that there is very little research to underpin practice. In my own research on this topic, I found most residents were checked at least once, and some were checked twice overnight. Somewhat concerning, some residents responded negatively to being woken. This practice was underpinned by staffs’ concern that residents were intractably incontinent and at risk of pressure injuries. No resident received toileting assistance and this decision was influenced by beliefs about limited staff-to-resident ratios.
Waking residents to provide them with toileting assistance or to check and change their pads disrupts the quality and duration of a resident’s sleep, which in turn may exacerbate their cognitive and functional decline. And, as you mention, it may distress residents, including those who are cognitively impaired. The right answer to overnight toileting is that decisions about care should be based on an individualised assessment that takes into account the frequency, severity, and type of the incontinence, the resident’s skin health, their natural sleep/wake status, their ability to spontaneously move in bed, and, most importantly, their personal preferences. Ideally, we should be reviewing practice to obtain objective information to help us make informed decisions about residents’ individual continence care needs over the 24 hour period.
Q: We have a lot of residents with dementia in our facility. How do we assess the best methods of toileting assistance for them?
A: There is no doubt the diagnosis of dementia complicates the management of incontinence. For example, it can make it difficult to obtain accurate information about the frequency of continence and incontinence. In addition, people with dementia may not always understand or appreciate a carer’s efforts to assist them to wash, use the toilet, or change a pad.
However, residents with dementia may have incontinence for the very same reasons as residents without dementia. They should receive the same assessment as residents without dementia. The ‘Continence Tools for Residential Aged Care’, available from the Australian Government Bladder and Bowel website which provides a structured process to assist staff in care home to conduct an individualised assessment of any resident's continence status and implement a targeted management plan.
Q: Often, the staff/residents ratio in RACFs are blamed for inadequate toileting assistance programs. At the hands on level how can we best work within our staffing capacity to identify which residents will likely respond to a toileting assistance program?
A: According to research conducted in the U.S., up to 50% of residents people living in aged care homes can maintain continence if they receive toileting assistance up to four times during a 12 hour day, particularly if they also participate in a program to improve their functional abilities. This includes residents with mild cognitive impairment. Providing residents with such assistance requires one staff member to five residents. This finding explains why many staff find it difficult to implement and sustain toileting assistance programs at rates that improve residents’ continence.
Whilst arguably all residents have the right to quality continence care, not all residents will derive benefit from a toileting assistance program. For example, a distressed response to toileting assistance should always be regarded as a form of communication and a desire to maintain independent bladder or bowel control. A realistic response to workforce constraints involves targeting those residents who are most likely to respond to a toileting assistance program.
In the first instance, residents should receive a multidisciplinary continence assessment in order to identify and address potentially reversible causes of incontinence, and to inform the development of an individualised continence care plan. The plan may or may not include the use of toileting assistance programs. The ‘Continence Tools for Residential Aged Care’, available from the Australian Government Bladder and Bowel website which provides an evidence-based set of resources to assist staff working in residential aged care facilities to conduct this assessment and to determine the most appropriate individualised intervention.
Q: What steps would you suggest to take before prescribing a laxative to a frail older adult?
A: The key to good bowel management is regular and ongoing assessment. Assess the frail older adult to identify and treat reversible causes of constipation including side effects of medication. Conservative treatment of constipation can include exercise, abdominal massage, increased fluids, fruit and fibre. This can be tailored according to the frail older adult’s individual needs.
A recent study undertaken by a Victorian regional health service showed it was possible to substantially reduce the need for suppositories to manage constipation among frail older adults in a dementia-specific unit by introducing new assessment guidelines to individualise residents’ care, and by increasing the use of non-laxative agents. Vigilant daily bowel charting was carried out using a stool form scale. Other measurements were also noted including behavioural response of resident, and if any laxatives administered for example, type & dose.
Before administering laxatives to the frail older adult, consideration is given to presenting symptoms, the individuals’ fluid intake, swallowing ability, diet & potential side effects of any medication currently taken.
In choosing a laxative, it is important to know how they work. Selection is also dependent of goals i.e. prevent constipation, increase bulk, to soften or push stool or a combination of these.
Q: I am a physiotherapist who has recently started working in an acute Older Adult Mental Health facility and have notedthat quite a number of our older female patients get recurrent UTI's. The increase in their confusion and being unwell adds significantly to their already present dementia-related confusion and other side-effects from further medications to treat the UTI's. Are you aware of "best practice " management of this population? I will be interested to hear your thoughts on this. Thank you.
A: This is a big topic and there is considerable debate about diagnosis and treatment. The signs and symptoms of UTI in older adults may include altered mental status, fever, haematuria, dysuria, urgency and suprapubic pain. You rightly note that UTIs can cause frail older adults particularly those with pre-existing dementia to develop delirium. Once, they have delirium they are at greater risk of falling.
Of course the question is one of treatment. The clinical assessment of people with dementia and living in care homes is challenging because of their limited verbal communication, and the difficulty of obtaining a clean catch specimen of urine. Moreover, frail older persons are at higher risk for unintended adverse effects from treatment (e.g., fulminate Clostridium difficile colitis from antibiotics used to treat otherwise asymptomatic bacteruria in the presence of urinary incontinence). Asymptomatic bacteruria should not be treated as it may increase antimicrobial resistance. The Society for Healthcare Epidemiology of American (SHEA) developed a set of minimum criteria to assist clinicians determine the appropriateness of antimicrobial therapy for individuals with advanced dementia. The clinical indicators include: acute dysuria OR fever, and ≥ one of the following symptoms: i) new or worse urinary frequency, (ii) urinary urgency, (iii) gross haematuria, (iv) suprapubic pain, (v) costovertebral tenderness, (vi) rigours, and (vii) changes in mental status.