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National audit of continence care for older people: Management of urinary incontinence
Abstract
the Department of Health report 'Good practice in continence services' highlights the need for proper assessment and management of urinary incontinence. The National Service Framework for Older People required service providers to establish integrated continence services by April 2004. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met.
the audit studied incontinent individuals of 65 years and over. Each site returned data on organisational structure and the process of 20 patients' care. Data were submitted via the internet, and all were anonymous.
the national audit was conducted across England, Wales and Northern Ireland. Data on the care of patients/residents with bladder problems were returned by 141/326 (43%) of primary care trusts (PCT), by 159/196 (81%) of secondary care trusts (involving 198 hospitals) and by 29/309 (9%) of invited care homes. In all 58% of PCT, 48% of hospitals and 74% of care homes reported that integrated continence services existed in their area. Whilst basic provision of care appeared to be in place, the audit identified deficiencies in the organisation of services, and in the assessment and management of urinary incontinence in the elderly.
the results of this audit indicate that the requirement for integrated continence services has not yet been met. Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need to re-establish the fundamentals of continence care into the practice of medical and nursing staff and action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.
... The proportion of residents using absorbing material varies from 54% (Rodriguez et al., 2007), 77% (Omli et al., 2010) to 84% (Brandeis et al., 1997). Scheduled toileting is applied in 27% (Rodriguez et al., 2007), 38,7% (Brandeis et al., 1997) up to 60% of the cases (Wagg et al., 2008). Other interventions such as change of clothing (11%), bladder program (from 6-16%) (Rodriguez et al., 2007), pelvic floor training (3%) and pharmacological interventions (14%) (Wagg et al., 2008) were less frequently applied. ...
... Scheduled toileting is applied in 27% (Rodriguez et al., 2007), 38,7% (Brandeis et al., 1997) up to 60% of the cases (Wagg et al., 2008). Other interventions such as change of clothing (11%), bladder program (from 6-16%) (Rodriguez et al., 2007), pelvic floor training (3%) and pharmacological interventions (14%) (Wagg et al., 2008) were less frequently applied. In 35.5% of the cases two or more interventions were used simultaneously (Brandeis et al., 1997). ...
... Less than two per cent of the persons in this study had other interventions than absorbing material, solely or as part of a combination of interventions. Our finding that, in general, absorbing material is the mostly used intervention, agrees with previous studies (Flanagan et al., 2012;Halfens et al., 2015;Roe et al., 2011;Wagg et al., 2008 primarily for persons unable to achieve independent (dry, not dependent on ongoing treatment) or dependent continence (dry with toileting assistance, behavioural treatment and/or medication) (Fonda & Abrams, 2006). An explanation for the use of absorbent material in the care independent group can be found in Johnson et al. (2001). ...
Aim
To explore the differences in managing urinary incontinence in residents in nursing homes aged 65 years or older in relation to their care dependency.
Design
The 2015 data of the Dutch annual independent (Inter)national Prevalence Measurement of Quality of Care of Maastricht University were used. The design involved a cross‐sectional, multi‐centre point prevalence measurement in hospitals, care homes, and home care.
Methods
Secondary data analysis on the data provided by care home organizations.
Results
In the care independent group, the solely use of absorbing material was the mostly applied intervention. In the group of care dependent persons, the combination of absorbing material with toilet on set times and on individual basis was the most common approach.
Conclusion
The outcome of this study indicated that the management of urinary incontinence in residents in nursing homes differs depending on their care dependency.
Impact
• Caregivers in nursing homes should be aware of preferences of residents regarding the management of their urinary incontinence.
• Researchers should investigate criteria used by caregivers and care receivers into the decision of the application of interventions for urinary incontinence.
... From a professional nursing perspective, these findings are demoralising. The present study finding is supported in other research where it was found that prescribing absorbent continence pads was the most common intervention used to target older people with UI (Dingwall, 2008;DuMoulin, Hamers, Ambergen, & Halfens, 2009;Wagg et al., 2008). Older women received additional information in the form of instructions about the importance of pelvic floor and bladder exercises and toileting routines in the study by DuMoulin et al. (2009);however, this was not the case with their male counterparts, to whom only absorbent continence pads were given. ...
... In addition, it is highly likely that older people were denied evidence-based treatments for UI. In a national audit conducted in the United Kingdom, Wagg et al. (2008) (Nazarko, 2018;Stenzelius et al., 2015), and that benefits can be gained via rehabilitation and continence promotion (Nazarko, 2013). ...
... ed and guided (i.e. lead by the RNs in care) as they carry out nursing practices. Consequently, the importance of RNs embracing relevant leadership at the point of care(Abraham, 2011) cannot be underestimated in the clinical practice of continence care; neither can the importance of RNs being visible as a role model in the provision of direct care.Wagg et al. (2008), andWagg et al. (2014) reported that there is an urgent need to re-evaluate the fundamentals of continence care with respect to the clinical practices of healthcare professionals, with a view to establishing an appropriately integrated continence care service. Therefore, RNs need to work according to professional and authorised standard ...
Aim: This study aimed was to illuminate nurses’ experience of continence care for older people receiving home care, either in their own home or in an assisted living facility.
Background: Registered nurses (RNs) have a major role to play in identifying and establishing appropriate actions regarding continence care for older people. However, the crucial nursing care pathway for continence care is commonly described as poor.
Methods: Interviews were conducted with 11 RNs providing home care, and the transcribed texts were analysed using inductive content analysis.
Result: The impressions of RNs were categorised according to four themes; perceptions of continence care, an open approach to continence care, the need for personalised aid fittings, and the importance of teamwork in continence care. Key findings were the importance of team work; the need for nurses to embrace leadership at the point of care and be more visible in terms of the provision of direct care; substantiation that evidence-based interventions, such as scheduled toileting and prompted voiding, should constitute the norm in continence care within the context of home care; and the need for nurses to support the right of older persons to receive an assessment of their continence problems; deemed to be the minimum standard of quality care.
Conclusion: The provision of continence care that is based on key nursing standards, such as evidence-based and person-centred care, as well as individualised continence care that is based on evidenced-based guidelines, would ensure an improvement in the continence care that is presently on offer to older people.
... 17 National audits and guidance regarding continence care have identified that healthcare professionals in acute care settings inconsistently identify, assess, manage and treat incontinence . [18][19][20] The Francis public inquiry report referred to continence as 'this most basic of needs' and yet it was the area of care most frequently singled out for complaint. 21 Reports have also raised concern in respect of insufficient staff support and education, weak service integration and liaison, inconsistent care planning and poor communication regarding continence care. ...
... Ethics approval Interviews were carried out in accordance with research governance ethics protocols and with Health Research Authority (HRA) approval (UWE Research Ethics Committee reference: HAS. 19.07.221). Written consent was provided by each participant prior to interview. ...
Background
Bladder and bowel control difficulties affect 20% and 10% of the UK population, respectively, touch all age groups and are particularly prevalent in the older (65+ years) population. However, the quality of continence care is often poor, compromising patient health and well-being, increasing the risk of infection, and is a predisposing factor to nursing and residential home placement.
Objective
To identify factors that help or hinder good continence care for patients aged 65 years and over in hospital medical ward settings. Medical care, not surgical, was our exclusive focus.
Methods
We conducted 27 qualitative interviews with nursing, medical and allied health practitioners in three hospitals. We used a purposive sample and analysed data thematically, both manually and with the aid of NVivo software.
Results
Interviews revealed perspectives on practice promoting or inhibiting good quality continence care, as well as suggestions for improvements. Good continence care was said to be advanced through person-centred care, robust assessment and monitoring, and a proactive approach to encouraging patient independence. Barriers to quality care centred on lack of oversight, automatic use of incontinence products and staffing pressures. Suggested improvements centred on participatory care, open communication and care planning with a higher bladder and bowel health profile. In order to drive such improvements, hospital-based practitioners indicate a need and desire for regular continence care training.
Conclusions
Findings help explain the persistence of barriers to providing good quality care for patients aged 65 years and over with incontinence. Resolute continence promotion, in hospitals and throughout the National Health Service, would reduce reliance on products and the accompanying risks of patient dependency and catheter-associated gram-negative bacteraemia. Robust assessment and care planning, open communication and regular continence care training would assist such promotion and also help mitigate resource limitations by developing safer, time-efficient continence care.
... -Subregistro, subnotificação e carência de rastreio do problema por parte da equipe de enfermagem (4,7,13,(15)(16)(19)(20) . ...
... Dadas essas crenças, analisavam que a situação de continência dessas pessoas não seria alterada por ações durante a internação hospitalar (7,15,18) . Para que os enfermeiros e a equipe multiprofissional identifiquem sistematicamente a IU e iniciem sua gestão a longo prazo, algumas medidas podem ser tomadas, entre elas a capacitação da equipe, alertando sobre tal condição, e os riscos de desenvolvê-la (17)(18)(19) . Ademais, a fim de melhorar o reconhecimento da IU, o rastreio das pessoas acometidas deve ser realizado por meio do histórico de enfermagem, com um item sobre a micção adicionado ao instrumento e se aqueles que apresentam IU, desejam melhorar tal situação (14,16,18) . ...
Objective:
to identify factors inherent in hospital care that favor urinary incontinence in the elderly.
Method:
an integrative review with Scopus, CINAHL and Pubmed searches. Includes original articles, no language restriction, published between 2008 and 2018. Rated level of recommendation and level of evidence were assessed using the Oxford Center for Evidence-Based Medicine classification. Exploited content through thematic analysis in light of the Donabedian model.
Results:
13 articles constituted the sample. There were factors such as the unjustified and indiscriminate use of devices such as the geriatric diaper; hospital structure adversely affecting the needs of the elderly; and deficit in screening, risk identification and underreporting of the problem favor urinary incontinence in the hospitalized elderly.
Conclusion:
modifiable factors related to hospital structures and care processes favor both the onset and worsening of urinary incontinence in the elderly.
... UI can negatively impact on the quality of life of family carers (Wagg, et al., 2008). 'Unpaid carers are an essential part of our health and social care systems, not only providing physical and emotional support, but also saving the government large amounts of money' (Jorgensen, Parsons & Jacobs, 2009, p. 2). ...
... They are entitled to support. In its absence, UI can be the determining factor in the family's decision for residential care (Getliffe & Thomas, 2007;Greene, 2000;Landi et al., 2003;Stewart, 2006;Taylor & Donnelly, 2006;Wagg et al., 2008). ...
The International Continence Association defines urinary incontinence (UI) as the involuntary leakage of urine (Abrams, et al., 2003; Getliffe & Thomas, 2007). UI is a symptom or a collection of symptoms, not a disease (Hope, 2007; Perry, 2008). UI is widely underreported and undertreated (Fonda & Newman, 2006; Getliffe & Thomas, 2007; Lara & Nancy, 1994). These circumstances reflect (at least in part) reluctance among many health care workers to face UI squarely (Hope, 2007; Locher, Burgio, Goode, Roth & Rodriguez, 2002). Part of this reluctance may be attributable to lack of skills and knowledge (Getliffe & Thomas, 2007; Hope, 2007; Locher et al, 2002). Reflective practitioners must also recognise, and guard against, being influenced by their own life experiences and beliefs (Phillips, Ray & Marshall, 2006) and by erroneous and unhelpful beliefs in the society at large (Brashler, 2006; Getliffe & Thomas, 2007; Hope 2007). Moreover, the failure of persons suffering chronic conditions to be ‘cured’ can elicit negative reactions from health workers (Brashler, 2006).Ageism, defined as ‘a set of beliefs, attitudes, social institutions, and acts that denigrate individuals or groups based on their chronological age’ negatively impacts on older persons’ health and well-being (Whitbourne, 2005, p. 51; see also Butler, 1975; Myers & Schwiebert, 1996; Wilson, Ruch, Lymbery, & Cooper, 2008). The beliefs of individuals, families and groups too often do not reflect the reality that most persons with UI can be helped (Fonda, 2006: Getliffe & Thomas, 2007; Naughtin & Schofield, 2009; Locher, et al., 2002). This article addresses how health care social workers can contribute to delivering this central message to clients, whanau and other caregivers.
... Pearson (2003) reported that in Australia, up to 125,000 older people living in nursing homes experienced UI and that this number was predicted to rise to 250,000 by 2030. Despite the high prevalence of UI among older people, urinary continence (UC) remains poorly assessed and managed in nursing homes (Australian Institute of Health & Welfare 2006), and its widespread impact on the health and quality of life of older people remains an under-studied area (Wagg et al. 2008). The lack of attention to the application of a personcentred approach to the management of UI has been noted (Nazarko 2013) and attributed to the feeling of powerlessness experienced by nursing staff who believe that they have no more to offer than routine toileting and incontinence pads (Duff & Clarke 2010). ...
... A cross-setting audit of UC practices in England and Northern Ireland found that community, acute and rehabilitation care settings showed deficiencies in UC assessment and management for older people (Coffey et al. 2007, Wagg et al. 2008. International UC guidelines focused on strategies to diagnose and treat UI, including exercises, drug treatments and surgery (Fantl et al. 1996, Martin et al. 2006, Th€ uroff et al. 2011, which may not be useful for promoting UC or manage UI for older people living in nursing homes. ...
To explore the effects of introducing a telemonitoring and care planning system for urinary continence assessment in a nursing home and adherence by care staff to urinary continence care plans.
Only a few studies have explored the effect of introducing telemonitoring system on urinary continence care, none for older people in nursing homes.
Pre- and postintervention repeated measures design.
Data for the study were collected from August-October 2011. Care staff were trained in the use of a telemonitoring system for continence assessment. Voiding events for each older person were recorded using the system during a 72-hour urinary continence assessment, and the data were used to prepare an individualised care plan. After two weeks of using the new care plan, a second assessment was carried out for each older person, using the telemonitoring system.
The participants were on average 81 years old and assessed as having high care needs. The statistically significant outcomes were as follows: reduced volume of urine voided into continence aids, reduced number of prescribed toileting visits, increased number of actual toilet visits, increased number of successful toileting events and increased adherence to urinary continence care plans by staff.
During a 12-week trial, urinary continence assessment and management of older people were improved. This suggests that the introduction of a suitably designed telemonitoring system combined with staff training can improve urinary continence care.
The results suggest that nursing homes can improve continence assessment and management practices by adopting an appropriately designed mobile, wireless telemonitoring system for continence assessment and providing the associated staff training programmes.
... Pearson (2003) reported that in Australia, up to 125,000 older people living in nursing homes experienced UI and that this number was predicted to rise to 250,000 by 2030. Despite the high prevalence of UI among older people, urinary continence (UC) remains poorly assessed and managed in nursing homes (Australian Institute of Health & Welfare 2006), and its widespread impact on the health and quality of life of older people remains an under-studied area (Wagg et al. 2008). The lack of attention to the application of a personcentred approach to the management of UI has been noted (Nazarko 2013) and attributed to the feeling of powerlessness experienced by nursing staff who believe that they have no more to offer than routine toileting and incontinence pads (Duff & Clarke 2010). ...
... A cross-setting audit of UC practices in England and Northern Ireland found that community, acute and rehabilitation care settings showed deficiencies in UC assessment and management for older people (Coffey et al. 2007, Wagg et al. 2008. International UC guidelines focused on strategies to diagnose and treat UI, including exercises, drug treatments and surgery (Fantl et al. 1996, Martin et al. 2006, Th€ uroff et al. 2011, which may not be useful for promoting UC or manage UI for older people living in nursing homes. ...
... Urinary and fecal incontinence affect many people and are common and embarrassing health problems. 1,2 Prevalence and review studies show urinary inconti-nence affects quality of life 1,3,4 and causes isolation and depression, and fecal incontinence can cause psychosocial problems such as loss of self-esteem, progressive isolation, and social stigmatization as well as reducing quality of life, 5,6 burdening patients and the community with high costs. 6 Urinary incontinence prevalence has been shown to be between 12% and 49.7% 1,[7][8][9][10][11][12] and fecal incontinence has a prevalence of between 2% and 16.9%. ...
Research related to the design and development of new incontinence containment products for women is scarce. PURPOSE: The purpose of this 2-part study was to 1) develop a new incontinence containment product for fecal incontinence and 2) examine the effect of this new product on the occurrence of incontinence-associated dermatitis (IAD). METHODS: In part 1, a new incontinence containment product was designed, developed, and trialed among 10 healthy female volunteers. The product was comprised of a double layer of polypropylene nonwoven fabric and 100% cotton interlock fabric with a 3-ply 100% cotton interlock fabric added into the perianal section. Participants wore the product for 8 hours and were asked to defecate into the product and evaluate its comfort, ability to contain liquids and protect privacy, any personal allergic reaction, and air permeability. In part 2, after any product modifications, 12 bedridden women treated in the neurology unit of a hospital in western Turkey who had an indwelling urinary catheter and fecal incontinence and who did not have diabetes mellitus, a darkly pigmented area in the perianal area, pressure injury, or erythema were randomized to 2 groups (study product and control, a premium adult diaper) and monitored for 8 days for the development and severity of perineal dermatitis (scored from 0 [no erythema] to 4 [broken, abraded skin]) using a skin assessment tool. Any type of erythema was considered IAD. Skin care (cleansing with a washcloth and water) was provided daily and after each defecation to all study participants. Data were collected via paper-and-pencil completion of the perineal skin integrity assessment and patient observation forms and entered into and analyzed by a computerized statistical program. Fisher's exact test and the chi-squared test were used to analyze the difference in IAD incidence and severity between the 2 groups, and the Mann Whitney U test was used to detect differences in the number and consistency of defecations. RESULTS: No statistically significant differences were noted among the characteristics of the 12 participants (6 in each group) except for age; patients in the study product group were significantly older (70.66 ± 10.36 vs 52.20 ± 16.78 years; P <.05. Four (4) patients in the study group exhibited 13 areas of perineal dermatitis (degree 1 = 6 areas; degree 2 = 6 areas; degree 3 = 1 area; and degree 4 = 0); 1 patient in the control group had 4 areas with degree 1. CONCLUSION: This prototype product is not sufficient to be used in clinical practice in patients with fecal incontinence, but further study in a larger population is warranted. Urinary and fecal incontinence affect many people and are common and embarrassing health problems. 1,2 Prevalence and review studies show urinary incontinence affects quality of life 1,3,4 and causes isolation and depression, and fecal incontinence can cause psychosocial problems such as loss of self-esteem, progressive isolation, and social stigmatization as well as reducing quality of life, 5,6 burdening patients and the community with high costs. 6 Urinary incontinence prevalence
... It has been highlighted that there is a lack of knowledge and training in relation to incontinence in dementia (Alzheimer Europe, 2014), with Wagg et al (2008) suggesting a propensity for healthcare professionals to provide continence pads to older people as a first action, rather than assessing and treating any underlying causes. Family carers have suggested that when they seek support from GPs and other healthcare professionals, advice is not always helpful or effective, with inconsistent access to continence products and a lack of understanding of the needs and impact on carers when considering which continence products might be appropriate (Drennan et al, 2011). ...
Urinary and faecal incontinence are common in the older population, yet incontinence is not a normal part of ageing. Dementia can impact upon a person's ability to remain continent, yet incontinence is unlikely to be a symptom of dementia until the latter stages of disease progression. There is a misconception that nothing can be done if a person with dementia experiences episodes of incontinence. However, many people with dementia often experience functional incontinence caused by immobility, communication difficulties, disorientation, or the inability to find the toilet, which can all be alleviated if the right support and advice is available. Improving the identification, assessment and management of continence issues can not only enable people wit dementia to maintain their dignity and improve their health, but also their sense of wellbeing and quality of life. There is also the possibility to improve relationships, reduce carer burden, and reduce the risk of a premature transition into a residential care setting. This fourth paper in the series explores some of the issues relating to dementia and continence and the impact as experienced by our two case studies, Dhriti Singh and Gregory Brewin.
... Treatment of incontinence will reduce reliance on products, as currently the number of individuals requiring a product is increasing year on year (Wagg et al, 2008;Murphy et al, 2019) Low-cost community interventions, such as lifestyle interventions, can cut product usage by 50% (Imamura et al, 2010) The multiprofessional approach to care must involve occupational therapy, physiotherapy, and other disciplines (such as learning disability or mental health nurses) as required, as this can support individualised toileting programmes, support patients with functional incontinence and help to reduce reliance on and costs of high absorbency containment products (Spencer et al, 2017) Reducing the use of indwelling catheters can help to reduce catheter-associated urinary tract infections in combination with evaluation, education, and training (Slyne et al, 2012; National Institute for Health and Care Excellence, 2023; Royal College of Nursing, 2021) Optimum symptom management can help to reduce infections (Shaw and Wagg, 2017) Some 50% of care home (with nursing) residents have faecal incontinence which can be a treatable condition (Leung and Schnelle, 2008). ...
The Association for Continence Professionals first published their guidance for the provision of absorbent products for adult incontinence in 2017. This consensus document is targeted towards commissioning leads, NHS Trust Boards, Bladder and Bowel leads, among others, and has been updated over the years to ensure that all adults who suffer with continence issues undergo a comprehensive assessment and have access to an equitable service. This article provides an overview of the latest guidelines which were published in February 2023.
... The prescribing of continence wear products as an initial intervention is not evidence-based best practice; unfortunately, there is reliance by some nurses to sanction continence wear as first line management intervention (Zürcher et al, 2011;HSE, 2019;NHS England, 2021). The results of a national audit reported that older people received continence care that was focused mainly on the use of containment products (Wagg at al, 2008). Positive proactive continence promotion treatment options are essential to prevent the risks of falls, reduce incidence of incontinence associated dermatitis, pressure sores development, prevent social isolation and reduce depression rates (Taylor and Cahill, 2017). ...
Urinary incontinence can have an overwhelmingly negative impact on an individual's quality of life. The personal, physical, psychosocial and sexual implications of urinary incontinence can affect health and well-being. This can increase the risk of falls, depression, anxiety, social isolation alongside a greater need for long-term care from a individual's own home. Statically, the prevalence rates of urinary incontinence increases with age; however, incontinence is not an inevitable or acceptable part of ageing—symptoms can be improved and managed effectively for suffers of this common condition.
Urinary incontinence can be challenging to assess, address and overcome for individuals. However health professionals need to have the expertise and experience to undertake a comprehensive continence assessment. When assessment is completed evidence-based interventions can be recommended, implemented and subsequently evaluated.
... Falls, pressure ulcers and moisture lesions are directly linked to poor continence care in older adults (DoH, 2014;Yates, 2017). Studies have also found that healthcare professionals in acute care settings inconsistently identify, assess and conservatively manage incontinence, citing evidence of inappropriate use of catheters and pads, weak care planning and insufficient staff support and training (Age UK et al., 2018;Orrell et al., 2013;Wagg et al., 2008). ...
Aim:
The aim of the study was to explore practitioners' experiences and perspectives on continence training, in order to understand its relevance to practice and how take-up of, and engagement with, such training may be improved.
Design:
27 qualitative interviews were conducted with nursing, medical and allied health practitioners in three hospitals.
Methods:
We analysed data thematically, both manually and with the aid of NVivo software. The research adheres to the consolidated criteria for reporting qualitative research checklist.
Results:
Practitioners asserted the likely benefits of evidence-based continence training, including more judicious use of products, reduction in associated infection, better patient skin care and more facilitative communication with patients. Practitioners also identified preferred methods of continence training, according to their role and workload. To ensure better take-up of, and engagement with, continence training, it must be authorized as essential and provided in ways that reflect professional preferences and pragmatic resource considerations.
... This catheter has been used in clinical care for more than 80 years, so is ripe for improvement from the current model. Across England, Northern Ireland and Wales, indwelling Foley catheters are used by 3% of people living in the community and 13% of care home residents (Wagg et al, 2007). ...
Nursing research has been developing, particularly over the past 15 years. The role of the clinical research nurse (CRN) is vital because of nurses' high level of patient contact. They are therefore involved in the identification of suitable study participants, initial contacts, enrolment, monitoring and follow-up. The COVID-19 pandemic has emphasised the importance of research to government, the NHS and patients. In this article, the author describes three research studies in which she has taken part and emphasises the importance of research and the role of CRNs in bringing together nursing, medicine and science through the CRN's specialist knowledge and how this particular career choice in nursing is now gaining greater attention and momentum.
... We could not explore how poor PFH is associated with sleep quality, as nocturia was not measured. Nocturia can result from medical conditions, not just pelvic floor function 3,5,7,9,10 . Targeted research is required to understand the factors related to poor sleep quality and psychological distress, and how these factors relate to PFH and frailty. ...
To determine the associations between pelvic floor health and frailty, and to identify variables associated with them, this study involved 656 community-dwellers aged 40–75 years who participated in a cross-sectional observational study. Participants completed the Pelvic Floor Bother Questionnaire and the Fried frailty phenotype assessment, and were assessed for putative predictors (sleep quality, body mass index, nutrition, psychological distress, hydration, smoking, alcohol, polypharmacy and health concerns). Differences were tested using analysis of variance models and chi square tests, and associations were tested using linear and logistic regression models. Bladder and bowel concerns were reported by men and women in all age groups, and 38% of participants exhibited at least one frailty element. There was a significant association between reporting frailty elements and poor pelvic floor health, and both were significantly associated with increasing age for men and women, poor sleep quality and high body mass index. Only pelvic floor health was significantly associated with health concerns and polypharmacy, and only frailty was significantly associated with smoking and alcohol consumption. Significant associations with alterable lifestyle and general health factors suggest that early interventions to improve pelvic floor health could impact on health and healthy ageing more broadly.
... In deze landen gebruikte 3 % van de mensen een verblijfskatheter, wat vergelijkbaar is met de uitkomsten uit onze studie. Bewoners van verzorgingstehuizen gebruikten daar in 13 % van de gevallen een verblijfskatheter [18]. We vermoeden dat het gebruik van verblijfskatheters en condoomkatheters ook substantieel hoger is in de Nederlandse zorginstellingen. ...
Samenvatting
Dit artikel geeft een overzicht van blaaskatheterisatie in Nederland tussen 1997 en 2018. Voor het maken van het overzicht is gebruikgemaakt van een databank met declaratie-informatie over extramurale hulpmiddelenzorg onder de verzekerde bevolking. Het aantal gebruikers wordt weergegeven per 100.000 personen. Het gebruik van verblijfskatheters is toegenomen van 159 (24.734 gebruikers) in 1997 naar 315 gebruikers per 100.000 personen (54.106 gebruikers) in 2018. Het gebruik van wegwerpkatheters verdrievoudigde van 92 (14.258 gebruikers) in 1997 naar 267 per 100.000 personen (45.909 gebruikers) in 2018. In 2018 had 20,7 % van de gebruikers een neurogeen en 44,9 % een niet-neurogeen onderliggend lijden. De totale kosten stegen van 27,7 naar 84,4 miljoen euro. De kosten voor intermitterende katheterisatie stegen het meest: van 16,4 naar 74,6 miljoen euro. Uit dit onderzoek blijkt dat in de afgelopen 21 jaar het gebruik van verblijfskatheters en wegwerpkatheters substantieel is toegenomen. Mogelijk komt dit door de stijging van incontinentiezorg bij ouderen en dat aan richtlijnen is toegevoegd dat intermitterende katheterisatie de voorkeur heeft boven een verblijfskatheter.
... An IC was used in 13% of care home residents. 17 We suspect that the use of indwelling and external catheters is also substantially higher in the Dutch care facilities (intramural). Although we put much effort into finding a suitable database on intramural use, this study only contains information about the extramural (outpatient) use of urinary catheters. ...
Background
Our aim was to evaluate the use of indwelling, intermittent and external urinary catheters in neurogenic and non-neurogenic bladder patients in the Netherlands from 1997 to 2018.
Methods
Data were retrieved from a population-based cohort containing information about the extramural use of medical devices in the insured population in the Netherlands. The insured population increased from 9.9 million people in 1997 to 17.1 million people in 2018 (64–100% of the Dutch population). Users are expressed by users per 100,000 insured people and total users, corrected for the overall Dutch population. The expenditures are corrected for inflation and expressed by total costs and costs per user.
Results
During this 21-year period, indwelling catheter (IC) users doubled from 159 per 100,000 people (24,734 users) to 315 per 100,000 people (54,106 users). Clean intermittent catheter (CIC) users increased from 92 per 100,000 people (14,258 users) in 1997 to 267 per 100,000 people (45,909 users) in 2018. Of all users, 20.7% had an associated neurogenic disorder and 44.9% a non-neurogenic disorder in 2018. The total expenditure on extramural use of urinary catheters increased from 27.7 million euros in 1997 to 84.4 million euros in 2018. IC costs increased from 6.0 million euros in 1997 to 6.7 million euros in 2018, while CIC costs rose from 16.4 million euros to 74.6 million euros. Urine drainage bag costs decreased from 17.2 million in 2001 to 5.3 million in 2018.
Conclusions
IC use has increased substantially over the past 21 years, despite the fact that CIC use increased as well. It seems that the main driver behind the prevalence in IC and CIC use, is the rise in incontinence care in older patients and the adaption of preferred CIC use in professional guidelines. At least one fifth of all users catheterize due to neurogenic reasons.
... A national audit for continence care in the UK 20 found that deficiencies in the organisation of care and the management of UI were more pronounced for older people. 40 For example, in acute and primary care settings, older people were less likely to have a continence history or focused examination done. In secondary care, while it has been shown that surgical treatments are safe and effective in older women, 41 these procedures were used less frequently than in younger patients. ...
Objective
To examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS).
Design
National cohort study.
Setting
NHS hospitals.
Participants
27 997 women aged 20 years or older who had a first SUI surgery in an English NHS Hospital between April 2013 and March 2016 and a diagnosis of SUI at the same time as the procedure.
Methods
Multilevel Poisson regression was used to adjust for geographic differences in age, ethnicity, prevalence of long-term illness and socioeconomic deprivation.
Primary outcome measure
Rate of surgery for SUI per 100 000 women/year at two geographic levels: Clinical Commissioning Group (CCG; n=209) and Sustainability and Transformation Partnership (STP; n=44).
Results
The rate of surgery for SUI was 40 procedures per 100 000 women/year. Risk-adjusted rates ranged from 20 to 106 procedures per 100 000 women/year across CCGs and 24 to 69 procedures per 100 000 women/year across the STP areas. These regional differences were only partially explained by demographic characteristics as adjustment reduced variance of surgery rates by 16% among the CCGs and 35% among the STPs.
Conclusions
Substantial geographic variation exists in the use of surgery for female SUI in the English NHS, suggesting that women in some areas are more likely to be treated compared with women with the same condition in other areas. The variation reflects differences in how national guidelines are being interpreted in the context of the ongoing debate about the safety of SUI surgery.
... There have been few attempts to systematically measure the quality of care provision for incontinence. A national clinical effectiveness project in England and Wales reported the variability of care and that quality care provision was in the hands of committed individuals, rather than a programmatic provision of services [7]. Aside from product guidelines on absorbent aids [8], there is a marked lack of auditable quality standards for toileting strategies and containment products [9]. ...
Introduction and hypothesis
Despite the range of treatment options available, relatively few people with incontinence find a total cure. The importance of daily management with toileting and containment cannot be underestimated. To our knowledge, there are no outcome measures to benchmark good care. The aim of this study was to create a set of key performance indicators (KPIs) to measure outcomes for toileting and containment.
Methods
An expert panel (EP) defined a set of KPIs using evidence from a scoping review, stakeholder engagement, and expert consensus. Peer reviewed articles, high-quality grey literature and international and national standards were reviewed to identify existing measures for management. These findings were augmented by an exercise involving patients, caregivers, nurses, clinicians, payers, policy makers and care providers to prioritise the findings and identify additional areas of interest.
Results
The final set of 14 KPIs includes quality indicators of process and outcome for those managed with a toileting and containment strategy and is relevant for both care-independent and -dependent persons. Rates of assessment, days waiting for specialist assessment, rates of return to work and those rating their quality of life as good or acceptable are captured. An indicator of well-being for caregivers and the economic costs of poor care are also defined.
Conclusions
The set of KPIs to measure outcomes from toileting and containment strategies describes the components of each to encourage integration into existing quality frameworks. Each KPI has been refined and detailed to encourage this. If implemented, resulting benchmarking data will facilitate care quality improvement and inform value-based care procurement and provision of toileting and containment strategies.
... Absorbent pads can increase the risk for incontinence as well as urinary tract infections and skin irritation (Omli et al., 2010;Wagg et al., 2013). Research suggests that absorbent pads are the most frequent continence management approach in frail elders across all settings (Du Moulin et al., 2009;Omli et al., 2010;Roe et al., 2010;Wagg et al, 2008;Zisberg, 2011). Pads should not be a substituted for an active approach to the prevention, diagnosis, and treatment of UI in frail elders (Wagg et al., 2013). ...
... 4 However, UI is often poorly managed in primary and secondary care settings. 5 While good evidence exists that conservative treatment and drug treatments are effective in managing UI in older people, 3,6 many people often remain undertreated. 3 Falls are also common among older people, often resulting in physical injuries, such as fractures, 7 and psychological deficits, such as loss of confidence and fear of further falls. ...
Aims:
To determine if urinary incontinence (UI) was an independent risk factor for falls and hip fractures in community-dwelling older men and women with complex needs, after controlling for confounders.
Methods:
Since 2012, all community care recipients in New Zealand have undergone standardized needs assessments using the Home Care International Residential Assessment Instrument (interRAI-HC). The interRAI-HC elicits information over multiple domains, including UI frequency and falls. Those aged 65+ years with assessment between July 1, 2012 and May 31, 2014 without collection devices or indwelling catheters were matched to hospital, mortality, and pharmaceutical databases, and apposite regression models applied.
Results:
Overall, 25 257 (37.5%) men and 42 032 (62.5%) women were eligible, with average age of 82.7 years (range: 65, 106 years). Incontinence was reported by 34.3% of men and 42.6% of women, falls within 90 days by 42.7% of men and 39.1% of women; and fractures recorded for 2.5% of men and 3.7% of women. In multivariable analysis, UI was significantly associated with falls (P < 0.001), and differentially related by sex (P < 0.001). Compared to continent participants, the odds of increasing falls risk was 1.69 (95% CI: 1.57, 1.82) for men with frequent incontinence and 1.53 (95% CI: 1.43, 1.64) for men with occasional continence; higher than the 1.39 (95% CI: 1.32, 1.46) and 1.33 (95% CI: 1.26, 1.39), respectively, for women. UI was not associated with hip fractures.
Conclusion:
UI is a common independent risk factor for falls but not hip fractures. Patterns are different between men and women with complex needs.
... La grande majorité des interventions étaient de type palliative (préventives : 18,1 % ; curatives : 26,4 %). Ces données sont confirmées par plusieurs auteurs qui mettent finalement en évidence, tout comme chez d'autres professionnels travaillant avec les personnes âgées, que les ID s'intéressent peu à l'IU et manquent de connaissances spécifiques [30] et/ou considèrent l'IU comme un phénomène normal du vieillissement [29,31]. Cependant, les ID conviennent que l'IU a de sérieuses conséquences sur la bonne santé physique, fonctionnelle, psychologique et sociale des personnes âgées [1,3,32]. ...
Afin d’optimiser nos pratiques en développant un programme interdisciplinaire de dépistage et de prise en charge des troubles fonctionnels urinaires avec incontinence urinaire (IU), cette étude prospective a permis d’évaluer les besoins qualitatifs et quantitatifs de nos patients âgés, polymorbides et polymédiqués. Tous les patients en miction spontanée hospitalisés dans l’unité de soins aigus aux seniors du CHUV entre le 1er février et le 31 mars 2016 ont été évalués à l’aide de l’ICIQ-UI-SF. Durant la période, sur les 87 patients évalués (âge moyen : 86,4 ± 6,7 ans ; 78,2 % de femmes), 41 avaient des pertes urinaires dont 23 présentaient des épisodes d’incontinence ≥ 1/jour (56,1 %). Pour 20, l’abondance était de quantité moyenne à importante (48,8 %). Le score moyen à l’ICIQ-UI-SF était de 12,3 ± 4,2 (min = 0, max = 21). Plus de la moitié des patients incontinents rapportaient des symptômes évoquant une IU d’effort ; 53,6 % déclaraient avoir des pertes avant de pouvoir arriver aux toilettes, sans que l’on puisse à ce stade distinguer une hyperactivité vésicale d’une origine fonctionnelle. Chez 11 patients, des épisodes de fuites urinaires nocturnes étaient rapportés. En comparaison aux autres, les patients avec IU étaient plus âgés (87,7 ± 4,8 vs. 85,5 ± 7,8 ans, p < 0,05) et présentaient plus de syndromes gériatriques (2,1 ± 0,6 vs. 1,8 ± 0,8, p < 0,05). Les troubles de la marche et de l’équilibre, les troubles cognitifs et le risque de dénutrition protéinoénergétique étaient significativement plus fréquents. Si les patients avec une IU prenaient significativement plus de médicaments (9,1 ± 4,0 vs. 8,4 ± 3,5, p < 0,05), il n’a pas été identifié de différence en termes de prévalence de prescriptions potentiellement inappropriées selon les critères STOPP/START. Cette étude apporte des réponses aux objectifs initialement posés et a conduit à l’élaboration d’un protocole interdisciplinaire et des recommandations thérapeutiques adaptées au profil de vulnérabilité des patients identifiés.
... It was suggested that it takes a member of staff seven minutes to help an older person use the toilet, four minutes to apply barrier cream and seven minutes to change clothes with the addition of 9% of time from RNs in supervising PCAs to deliver a UC care plan (Frantz et al 2003). Despite its impact and high prevalence, UI is not assessed nor managed effectively (Hawthorne 2006; Taunton et al 2005) and remains an under-studied area of healthcare research (Wagg et al 2008). The most commonly used strategies to promote UC in nursing homes are toileting assistance programs and the use of continence aids (Roe et al 2011). ...
Objective Exploring urinary continence (UC) assessment and management practices in Australian nursing homes. Design Mixed method using a questionnaire and interviews. Setting Five nursing homes in Australian metropolitan cities. Subjects Participants 121 staff: mostly female (91%) with a range of roles including personal care assistants (PCAs) (63%), enrolled nurses (ENs) (11%), registered nurses (RNs) (20%) and managers (4%). Main outcomes measure(s) Compliance with and perceptions about UC assessment and management. Results 77% (n=71) of care staff (PCAs, ENs and RNs) were compliant with the UC management protocol of checking for wetness every 2 to 2.5 hours. Toileting time and frequency of changing continence aids varied between nursing homes. Perceptions about the accuracy of UC assessments and knowledge of an older person following UC assessment also differed between nursing homes. Conclusion Areas where UC assessment and management in nursing homes could be improved include identifying the voiding times of older people, compliance with care plans in management practice, and caregiver ability to assess the capacity of continence aids to absorb urine. Training for effective continence care in nursing homes needs to be enhanced.
... Coffey, McCarthy, McCormack, Wright & Slater, 2007; Dumoulin, Korner-Bitensky & Tannenbaum, 2007 ; Hancock, Bender, Dayhoff & Nyhuis, 1996 ; Wagg, Potter, Peel, Irwin, Lowe, & Pearson, 2008) [22][25]. Certaines infirmières considèrent que c'est un phénomène normal lié à la vieillesse(Haslam, 2004) [26], mais conviennent néanmoins qu'elle a de sérieuses conséquences sur la santé des personnes âgées, (Dumoulin, Hamers, Ambergen & Halfens 2009)[27] ; notamment au niveau de l'altération de l'autonomie fonctionnelle dans ses dimensions physique et psychologique(Faltin, 2009 ;Farage et al, 2008) [9,11]. ...
Urinary incontinence in aged hospitalised geriatric patients : is it really a priority for nurses ?
Introduction : urinary incontinence (UI) is a phenomenon with high prevalence in hospitalized elderly patients, effecting up to 70% of patients requiring long term care. However, despite the discomfort it causes and its association with functional decline, it seems to be given insufficient attention by nurses in geriatric care.
Objectives : to assess the prevalence of urinary incontinence in geriatric patients at admission and the level of nurse involvement as characterized by the explicit documentation of UI diagnosis in the patient’s record, prescription of nursing intervention, or nursing actions related to UI.
Methods : cross-sectional retrospective chart review. One hundred cases were randomly selected from those patients 65 years or older admitted to the geriatric ward of a university hospital. The variables examined included : total and continence scores on the Measure of Functional Independence (MIF), socio-demographic variables, presence of a nursing diagnosis in the medical record, prescription of or documentation of a nursing intervention related to UI.
Results : the prevalence of urinary incontinence was 72 % and UI was positively correlated with a low MIF score, age and status of awaiting placement. Of the examined cases, nursing diagnosis of UI was only documented in 1.4 % of cases, nursing interventions were prescribed in 54 % of cases, and at least one nursing intervention was performed in 72 % of cases. The vast majority of the interventions were palliative.
Discussion : the results on the prevalence of IU are similar to those reported in several other studies. This is also the case in relation to nursing interventions. In this study, people with UI were given the same care regardless of their MIF score MIF, age or gender. One limitation of this study is that it is retrospective and therefore dependent on the quality of the nursing documentation.
Conclusions : this study is novel because it examines UI in relation to nursing interventions. It demonstrates that despite a high prevalence of UI, the general level of concern for nurses remains relatively low. Individualized care is desirable and clinical innovations must be developed for primary and secondary prevention of UI during hospitalization.
... Conclusion The majority of men seen within the NHS with LUTS do not receive management according to the reported care of men with lower urinary tract symptoms in primary (PC) and acute hospitals (AH), assessed against the new NICE guidelines to serve as a benchmark against which future audits might be compared. Of particular interest, given the thrust of the service guidelines in "Good practice in Continence Services" [7] that the majority of people with urinary incontinence (UI) can be cared for in primary care and the findings from the previous audit of continence care in older people [8], which found substandard care for older people was the pattern of treatment and a comparison of the care received by younger and older men. This report concentrates on the initial assessment of men with LUTS and the recommendations therefrom [9]. ...
Objective:
To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in men.
Design:
Retrospective survey of male patients with UI in primary and acute hospital (AH) care as part of a national audit.
Setting:
NHS AH and primary care (PC) trusts.
Sample:
Twenty-five men <65 years old and 25 men ≥65 years old from each participating site.
Methods:
All NHS trusts in England, Wales Northern Ireland and Channel Islands were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous, and access to the web tool was password protected for confidentiality.
Results:
Data were returned by 80 % (128/161) of acute trusts and 52 % (75/144) of PC trusts in England, and 71 % (10/14) of combined trusts from Northern Ireland, Wales and the Channel Islands including data on 559 men <65 and 1271 65+ from 141 sites within acute hospitals and 445 men <65 and 826 men 65+ in PC, a total of 3101 participants.
Conclusion:
The majority of men seen within the NHS with LUTS do not receive management according to evidence-informed NICE guidelines; in general, older men are less likely to receive care that meets guideline standards than younger men.
... Despite its impact and high prevalence, UI is not assessed nor managed effectively (Hawthorne 2006;Taunton et al 2005) and remains an under-studied area of healthcare research (Wagg et al 2008). The most commonly used strategies to promote UC in nursing homes are toileting assistance programs and the use of continence aids (Roe et al 2011). ...
... The US government sets minimum quality standards for UI assessment and management in long term care, but these standards, along with basic fundamental principles of UI, are poorly understood by long term staff [156]. Two groups, the US Assessing Care of Vulnerable Elders (ACOVE) project and the UK Clinical Effectiveness and Evaluation Unit, have developed quality performance measures for UI care in frailer older persons, using structured literature review and expert panel review [157][158][159][160]. These measures are not guidelines per se, and in some instances lack sufficient detail. ...
Urinary incontinence (UI) is common among the elderly, but the literature is sparse on the surgical treatment of UI among the elderly. This systematic review aims to assess the effectiveness of surgical interventions as treatment for urinary incontinence in the elderly population ≥65 years of age.
Randomized controlled trials (RCT) and prospective nonrandomized studies (NRS) were included. The databases PubMed (NLM), EMBASE (Elsevier), Cochrane Library (Wiley), and Cinahl (EBSCO) were searched for the period 1966 up to October 2013. The population had to be ≥65 years of age and had to have undergone urethral sling procedures, periurethral injection of bulking agents, artificial urinary sphincter surgery, bladder injection treatment with onabotulinumtoxin A or sacral neuromodulation treatment. Eligible outcomes were episodes of incontinence/urine leakage, adverse events, and quality of life. The studies included had to be at a moderate or low risk of bias. Mean difference (MD) or standard mean difference (SMD)as well as risk difference (RD) and the 95 % CI were calculated.
Five studies-all on the suburethral sling procedure in women- that fulfilled the inclusion criteria were identified. The proportion of patients reporting persistent SUI after surgery ranged from 5.2 to 17.6 %. One study evaluating quality of life (QoL) showed a significant improvement after surgery. The complication rates varied between 1 and 26 %, mainly bladder perforation, bladder emptying disturbances, and de novo urge.
The suburethral sling procedure improves continence as well as QoL among elderly women with SUI; however, evidence is limited.
... UI is poorly managed in the community (Wagg et al, 2008). Nurse specialists and community nurses in primary care can improve the knowledge of community-dwelling women and outcomes for people who have UI (Albers-Heitner et al, 2012). ...
As the population ages, the risk and prevalence of urinary incontinence (UI) will increase. Although this is the case, many women do not seek help or treatment. It is therefore important to investigate women's knowledge of UI. This pilot study aimed to describe community-dwelling women's knowledge of UI. A convenience sample method was used to recruit 50 community-dwelling women aged 50 and over. Some 36 participants completed a demographic questionnaire and the Urinary Incontinence Knowledge Scale (UIKS)-a response rate of 72%. The findings indicated that participants had poor knowledge of UI, principally in relation to risk, prevention, treatment and management factors. Fewer than 20% of participants indicated they had been given information on bladder and bowel health issues. The findings suggested that women had unmet educational needs relating to UI. Community nurses have a key role to play in promoting targeted awareness and continence education advice regarding UI to community-dwelling women.
Bladder and bowel problems can affect people of all ages, and can lead to feelings of anxiety, embarrassment and despair. Their management is a fundamental issue, particularly for those who have a neurogenic bladder. Discussing elimination can be a difficult subject to broach. Sue Thomas highlights the significant cost of constipation in terms of health outcomes, quality of life and the NHS.
Background
Performance of function-preserving hospitalization processes related to patient mobility, use of continence aids and food intake is significantly associated with outcomes in older adults. Nurses are the front-line personnel responsible for promoting performance of such processes. The degree to which nurse staffing is related to this performance is unclear.
Objective
To identify nurse-staffing characteristics and nursing-related care needs associated with older patients’ mobility, continence care and food intake during acute hospitalization.
Design
Cross-sectional study using survey data from the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) cohort study combined with day-level administrative nurse staffing data and clinical day-level aggregated data for all patients hospitalized during the HoPE-FOR study period.
Setting
Internal medicine units in two medical centres in Israel.
Participants
Eight hundred seventy-three older adults.
Methods
Mobility, continence care and food intake were assessed within 2 days of admission using validated questionnaires. Nurse-to-patient ratios and nursing-skill mix (i.e. registered nurses (RNs), nurse aides, nurses with advanced clinical training and RNs with an academic degree) were assessed using administrative data. Decision trees were developed for mobility, continence care and food intake, applying classification and regression-tree analysis.
Results
The mobility decision tree identified three characteristics subdividing patients into six nodes: pre-admission functioning, pre-admission activity level and percentage of nurses with advanced training. The percentage of nurses with advanced training classified low-functioning patients into those walking in corridors versus walking or sitting only inside the room. The continence-care classification decision tree identified two characteristics that subdivided the patients into four nodes: pre-admission functioning and bladder control. Nurse-to-patient-ratio variables and patients’ nursing-related care needs did not contribute to this classification. The food-intake decision tree identified four characteristics—pre-admission functioning, gender, percentage of nurses with advanced training and percentage of nurse aides—subdividing patients into eight nodes. Low-functioning patients exposed to a higher percentage of nurses with advanced training had food-intake scores 14% higher than patients exposed to a lower percentage of nurses with advanced training. Independent men exposed to a higher percentage of nurse aides had a 14% higher habitual daily in-hospital food-intake score than independent men exposed to a lower percentage of nurse aides.
Conclusions
A higher percentage of nurses with post-graduate education is associated with better performance of mobility and food intake of hospitalized older adults. To maintain the potential benefits of highly trained staff, education levels should be considered in scheduling and assignment decision-making processes in internal medicine units.
Tweetable abstract: A higher percentage of nurses with post-graduate education is associated with better mobility and food intake of hospitalized older adults.
Background
Evidence‐based guidelines for the management of frail older persons with urinary incontinence are rare. Those produced by the International Consultation on Incontinence represent an authoritative set of recommendations spanning all aspects of management.
Aims
To summarize the available evidence relating to the management of urinary incontinence in frail older people published since the 5th International Consultation on Incontinence.
Materials and Methods
A series of systematic reviews and evidence updates were performed by members of the working group to update the 2012 recommendations.
Results
Along with the revision of the treatment algorithm and accompanying text, there have been significant advances in several areas of the management of lower urinary tract symptoms in frail older people.
Discussion
The committee continues to note the relative paucity of data concerning frail older persons and draw attention to knowledge gaps and research opportunities. Clinicians treating older people with lower urinary tract symptoms should use the available evidence from studies of older people combined with careful extrapolation of those data from younger subjects. Due consideration to an individual's frailty and wishes is crucial.
Introduction : Plus de trois millions de français souffrent d’incontinence urinaire et saprévalence augmente avec l’âge. Cette pathologie ne semble pas considérée commeune déficience pour laquelle un spectre large d’interventions est mis en place car lesinterventions « palliatives » sont retrouvées le plus souvent.Objectif : Identifier les potentiels déterminants de la prise en charge palliative del’incontinence urinaire chez le sujet âgé afin d’aborder une réflexion éthique.Méthode : Revue narrative de la littérature en langue française et anglaise sur les basesde données Medline, CAIRN, et sur les sites internet de la Haute Autorité de Santé et duMinistère Français de la Santé. Les articles ont été retenus s’ils apportaient des élémentsde réponse originaux dans la recherche des déterminants de la prise en charge palliativede l’incontinence urinaire du sujet âgé.Résultats : 241 articles retrouvés et 98 retenus. Après analyse des articles sélectionnésnous avons identifié des déterminants potentiels de la prise en charge palliative del’incontinence urinaire : marché rentable et porteur, risque de choix orienté par les coûts, formations soignantes par les fabricants, fidélisation des patients, banalisation etautogestion des symptômes, pathologie tabou, complexe, multifactorielle et chronophage, formation soignante déficiente, peu de recommandations spécifiques validées, traitements médicamenteux risqués, déserts médicaux, fidélisation des officines, exigence de propreté des corps et des lieux, surcharge de travail.Conclusion : Nécessité de sensibiliser les soignants à cette pathologie fréquente afin demieux l’intégrer dans la prise en charge globale de la personne âgée
Objectives:
Fecal incontinence (FI) is a problem in growing older populations. Validating a suspected association between FI and mortality in community dwelling older adults could lead to improved planning for and management of the increasing complex older population. In a large cohort of New Zealand older adults, we assessed the prevalence of FI, urinary incontinence (UI), combined FI and UI, and their associations with mortality.
Methods:
This study consisted of a retrospective analysis of international standardized geriatric assessment-home care (InterRAI-HC) data from community-dwelling adults aged 65 years or older, who met the criteria required for the InterRAI-HC, having complex needs and being under consideration for residential care. The prevalence of UI and FI was analyzed. Data were adjusted for demography and 25 confounding factors. Mortality was the primary outcome measure.
Results:
The total cohort consisted of 41,932 older adults. Both UI and FI were associated with mortality (P<0.001), and risk of mortality increased with increased frequency of incontinence. In the adjusted model, FI remained significantly related to survival (P<0.001), whereas UI did not (P=0.31). Increased frequency of FI was associated with an increased likelihood of death (hazard ratio 1.28).
Conclusions:
This large national study is the first study to prove a statistically significant relationship between FI and mortality in a large, old and functionally impaired community. These findings will help improve the management of increasingly complex older populations.Am J Gastroenterol advance online publication, 1 August 2017; doi:10.1038/ajg.2017.200.
Aim:
To assess the association between baseline urinary incontinence and long-term, all-cause mortality.
Background:
Urinary incontinence is a common disorder among older institutionalised adults, with important consequences for morbidity and quality of life. Moreover, while it is a consistent mortality marker, the extent to which this association might be causal remains controversial.
Design:
A cohort study.
Methods:
We conducted a mortality follow-up study on a cohort of 675 nursing-home residents in the city of Madrid (Spain), from their 1998-1999 baseline interviews to September 2013. Study subjects or their caregivers were asked whether the resident had experienced any involuntary leakage of urine in the preceding 14 days, with subjects being subsequently defined as continent, mildly incontinent, or severely incontinent. Hazard ratios for all-cause mortality were estimated using Cox proportional hazards models.
Results:
After a 4061 person-year follow-up (median/maximum of 4·6/15·2 years), 576 participants had died. In fully-adjusted models, urinary incontinence was associated with a 24 per cent increased risk of all-cause mortality. There was a graded relationship across severity levels, with hazard ratios 7% higher for mild and 44% higher for severe incontinence as compared with the continent group. The adjusted mortality fraction attributable to urinary incontinence was 11 per cent.
Conclusion:
It would appear that urinary incontinence is not only a marker but also a real determinant of survival in the institutionalized population. This finding, which seems plausible in a population of frail older adults, warrants further research into mechanisms that could help to elucidate this hypothesis.
Urinary incontinence is a condition that can affect many people as they get older. Clare Smart offers an insight into the option of urinary sheaths, which, if used correctly, can have a positive impact on a man's quality of life
Pike D et al (2015) Nurse-led treatment for occipital neuralgia. Nursing Times; 111: 32/33, 20-22. Occipital neuralgia is a headache resulting from dysfunction of the occipital nerves. Medically resistant occipital neuralgia is treated by greater occipital nerve injection, which is traditionally performed by neurologists. A nurse-led clinic was developed to try to improve the service. Patient feedback showed that the clinic was positively perceived by patients, with most stating the nurse-led model was more efficient than the previous one, which had been led by consultants.
The needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.
Objectives
The EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.
Design
Mixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.
Setting
General practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.
Participants
People with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.
Main outcome measures
Dementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.
Results
An educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.
Conclusions
A tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.
Trial registration
EVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.
Funding
This project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.
To describe the quality of incontinence care in nursing homes. Main outcome measures were: (1) availability of structural quality indicators on ward and institutional levels; (2) use of nursing interventions as quality indicators on a process level; (3) prevalence of incontinence as an outcome indicator.
Incontinence in older people is a major problem in nursing care that presents a high workload for nurses, increases costs and places a high burden on affected individuals. The availability of structural indicators, and the use of nursing interventions, is recommended to improve the quality of care. Only limited amounts of reliable and valid data are available regarding the quality of incontinence care in nursing homes.
A cross-sectional multicentre study in 16 nursing homes (N = 1302) in 2013.
A standardized and validated questionnaire was used for data collection. Each resident was assessed by two trained nurses.
The primary outcome of the study indicated that structural indicators, such as the availability of information brochures, are limited in nursing homes. On a process level, the provision of body worn pads or underlay pads to protect beds or chairs were most frequently used and training interventions were only delivered to a small proportion of residents with incontinence. The prevalence of all types of incontinence, particularly double incontinence, was high (69·2%).
Due to the high prevalence of double incontinence and low rate of training interventions regarding this type of incontinence, ongoing efforts to improve the quality of incontinence care are warranted.
© 2015 John Wiley & Sons Ltd.
Urinary incontinence can result from a stroke, leading to a range of psychological and physical difficulties. Providing adequate continence care is an important step in recovery.
Vice Chair of the Relatives & Residents Association. Patricia Duff OBE, and Alison Clarke, health and wellbeing campaign project worker for R&RA shed light on how relatives feel about continence provision.
Urinary incontinence is a common symptom after stroke and affects between 32% and 79% of patients. The National Sentinel Audit report by the Intercollegiate Stroke Working Party (2008a) indicates that urinary incontinence is better managed in designated stroke units, rather than in general medical wards. This literature review explores the causes of urinary incontinence after stroke and examines pertinent issues for rehabilitation practice. The literature showed that nursing staff attribute their negative attitudes towards patients with incontinence to a lack of education specific to continence assessment and management. Although education often focuses on containment of incontinence, rather than continence promotion, continence assessment is key to the development of the individual's continence promotion plan.
To synthesize evidence from systematic reviews on the management of urinary incontinence and promotion of continence using conservative/behavioural approaches in older people in care homes to inform clinical practice, guidelines and research.
Incontinence is highly prevalent in older people in care home populations.
Systematic review of systematic reviews with narrative synthesis.
Electronic searches of published systematic reviews in English using MEDLINE and CINAHL with no date restrictions up to September 2013. Searches supplemented by hand searching and electronic searching of Cochrane Library and PROSPERO.
PRISMA statement was followed, as were established methods for systematic review of systematic reviews.
Five systematic reviews of high quality were included, three specific to intervention studies and two reviewed descriptive studies. Urinary incontinence was the primary outcome in three reviews with factors associated with the management of urinary incontinence the primary outcome for the other reviews.
Toileting programmes, in particular prompted voiding, with use of incontinence pads are the main conservative behavioural approach for the management of incontinence and promotion of continence in this population with evidence of effectiveness in the short term. Evidence from associated factors; exercise, mobility, comorbidities, hydration, skin care, staff perspectives, policies and older people's experiences and preference are limited. The majority of evidence of effectiveness are from studies from one country which may or may not be transferable to other care home populations. Future international studies are warranted of complex combined interventions using mixed methods to provide evidence of effectiveness, context of implementation and economic evaluation.
© 2015 John Wiley & Sons Ltd.
Urinary incontinence in older people remains a poorly researched area of care, despite the scale and impact of the problem both to older people and to healthcare providers in terms of service delivery and cost. Whilst there are relatively few data specifically regarding interventions in older people, there is much that can be gained from existing evidence without too much extrapolation. This article deals with the assessment and management of urinary incontinence in the elderly, reviews the current evidence and speculates upon future directions.
Introduction: Pelvic floor muscle function of 30 overweight postmenopausal women prior to and after colporrhahpy was monitored in this study. Material and Methods: Patients diagnosed with cystokele or combined cystorectokele was involved. 1 mg oral estriol and local estriol cream were administered for 30 days preoperatively. Pelvic floor muscle function was monitored by surface electromyography 1 month before (1st) 1 day prior to surgery (2nd), and six weeks after the surgery (3rd measurement). Body composition parameters (intra- and extracellular water and body fat) were also measured. Results: The ability to relax significantly improved (p = 0.03) in the preoperative period (between 1st and 2nd occasions). Six weeks after surgery a non-significant (p = 0.054) decrease in average muscle activity was detected when compared with values obtained before the surgery. Muscle-activity declined significantly from the first to the last measurements (p = 0.005). Conclusion: Our results confirm that postmenopausal obese women who undergo anterior or posterior colporrhaphy need a follow-up concerning pelvic floor muscle function and suggest that physiotherapy started the earliest possible may aid in preserving postoperative functionality on the long run.
Studies of older people in long term care have shown that urinary and faecal incontinence are more prevalent in this group than among older people in the community.1 2 3 However, data describing the size of the problem in all types of long term care are lacking. We determined the prevalence of incontinence to assess the use of aids among older people in long term care.
In November 1990 a census of all people aged 65 years and over in long term care was carried out in Leicestershire.4 Data were collected on health, dependency, and the use of continence aids. Residents experiencing at least one incontinent episode weekly were defined as being incontinent …
this study examined the association between medically recognized urinary incontinence and risk of several disease conditions, hospitalization, nursing home admission and mortality.
review and abstraction of medical records and computerized data bases from 5986 members, aged 65 years and older, of a large health maintenance organization in northern California.
there was an increased risk of newly recognized urinary incontinence following a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure in both men and women, after adjustment for age and cohort. The risk of hospitalization was 30% higher in women following the diagnosis of incontinence [relative risk (RR) = 1.3, 95% confidence interval (CI) = 1.2-1.5] and 50% higher in men (RR = 1.5, 95% CI = 1.3-1.6) after adjustment for age, cohort and co-morbid conditions. The adjusted risk of admission to a nursing facility was 2.0 times greater for incontinent women (95% CI = 1.7-2.4) and 3.2 times greater for incontinent men (95% CI = 2.7-3.8). In contrast, the adjusted risk of mortality was only slightly greater for women (RR = 1.1; 95% CI = 0.99-1.3) and men (RR= 1.2; 95% CI= 1.1-1.4).
urinary incontinence increases the risk of hospitalization and substantially increases the risk of admission to a nursing home, independently of age, gender and the presence of other disease conditions, but has little effect on total mortality.
The aim of the study was to establish the prevalence of urinary symptoms and felt need in adults. This paper discusses problems with setting thresholds to distinguish cases from non-cases in this field of research. Few studies have provided detailed age- and sex-specific prevalence estimates for felt need in relation to urinary symptoms.
A cross-sectional postal survey was carried out of 15,904 community-dwelling adults aged 40 years or more registered with general practitioners in Leicestershire. Subjects were selected randomly by household from the Leicestershire Health Authority Register. The postal questionnaire consisted of questions on general health, urinary and bowel symptoms, quality of life, service use and demographic characteristics.
Thirty-four per cent of the sample reported clinically significant symptoms. The prevalence and severity of symptoms increased with age. However, only 2 per cent of the sample reported symptoms that were clinically significant, bothersome and socially disabling.
Urinary symptoms are very common in adults over 40 years of age living in the community. However, symptom-based estimates probably overestimate the level of need for health care in the community. It may be more effective and efficient to target services, in the first instance, on those people who report clinically significant symptoms that are bothersome or socially disabling. A consensus on thresholds and definitions of urinary symptoms is required to standardize clinical and research work and to target services more appropriately.
the National Centre for Health Outcomes Development has produced outcome indicators for the assessment of quality of care in the management of urinary incontinence. Three measures relate to the management of older people in long-term care: the prevalence of incontinence, the use of indwelling catheters and clinical assessment rates.
to evaluate the recommended outcome measures in clinical practice.
participating centres included residential homes, nursing homes and long-stay wards. We sent a structured questionnaire to each centre for qualitative assessment of the acceptability of the outcome indicators. We analysed data collected by nurses and other staff who used the urinary incontinence section of the Royal College of Physicians Continuous Assessment Review and Evaluation scheme audit tool for long-term care.
there were 1125 residents in 17 residential homes, 14 nursing homes and five long-stay wards. The overall prevalence of urinary incontinence was 34% in residential homes (range 2-86%), 70% in nursing homes (38-100%) and 71% in long-stay wards (4-97%). Catheterization rates were 5% in residential homes (0-20%), 10% in nursing homes (0-44%) and 6% in long-stay wards (0-20%). Rates of full clinical assessment were 48, 24 and 36% respectively.
there is great variability in these outcome measures within and between settings. Interpretation of outcome results requires more precise details on case-mix and the definition of outcome measures. Individual units found the audit tool helpful, but we advise caution with interpretation of outcomes between units.
To evaluate the effectiveness of conservative treatment in the community-based elderly (aged > or = 55 years) with stress, urge, and mixed urinary incontinence.
Systematic review of before-after studies or randomized controlled trials on the effect of exercise and drug therapy in urinary incontinence.
Reduction of urinary accidents, patient's perception, cystometric measurement, perineometry, and side effects.
MEDLINE (1966-2001), EMBASE (1986-2001), Science Citation Index (1988-2001), The Cochrane Library, and PiCarta were searched. RESULTS Four before-after studies and 4 randomized controlled trials were identified. Drug therapy alone: no study of sufficient quality. Drug therapy compared with behavioral therapy, 3 studies: bladder-sphincter biofeedback reduced urinary accidents in cases of urge or mixed incontinence by 80.7%, significantly better than oxybutynin (68.5%) or placebo (39.4%). Adding drug to behavioral treatment or behavioral to drug treatment also resulted in significant reduction in urodynamic urge incontinence (57.5%-88.5% vs 72.7-84.3%). Pelvic floor exercises alone reduced urinary accidents by 48% (compared with 53% for phenylpropanolamine) in patients with mixed or stress incontinence. Behavioral therapy, 5 studies: bladder-sphincter biofeedback in case of urge or mixed incontinence, bladder training in case of urge incontinence and pelvic floor exercises in case of stress incontinence reduced the urinary accidents with 68% to 94%.
There are only a few studies of sufficient methodological quality on the effect of conservative treatment of urinary incontinence in the elderly. Behavioral therapy reduced urinary accidents; the effect of drug therapy is unclear. We recommend behavioral therapy as first choice.
Background:
The role of informal spousal caregivers has increased as the population ages, levels of disability in society increase, and governments seek to restrain expenditure on the provision of institutional health care. Care giving has attracted a vast body of research, largely directed at caregiver burden. Incontinence, however, has been relatively unexplored, despite being a common problem faced by caregivers, and being recognised as a major caregiver burden and predictor of institutional placement.
Aims:
This study began to explore the impact of care recipient incontinence on major care providers, that is, their spouses.
Approach:
A qualitative approach based on the grounded theory method was used. Eight home-based caregivers of spouses with incontinence were interviewed.
Findings:
Data analysis revealed a number of categories, grouped under three major themes: underpinnings, processes and consequences. The underpinnings were lifelong love and friendship, and acceptance; the processes were problem-solving and constant watchfulness. The consequences were role change, financial cost, decreased intimacy, emotional responses, sleeping issues and social isolation.
Discussion:
The research highlighted the interconnectedness of factors in the experiences of carers, reinforcing the need for holistic assessment beyond a focus on the "continence issue" alone. Nevertheless, simple interventions could make substantial differences. A framework is proposed which may guide nursing assessment.
The prevalence of urinary incontinence was investigated by determining the number of incontinent patients under the care of various health and social service agencies in two London boroughs and by a postal survey of the 22 430 people aged 5 years and over on the practice lists of 12 general practitioners in different parts of the country. The prevalence of incontinence known to the health and social service agencies was 0.2% in women and 0.1% in men aged 15-64 and 2.5% in women and 1.3% in men aged 65 and over. The postal survey, to which 89% of the people whose correct address was known replied, showed a prevalence of urinary incontinence of 8.5% in women and 1.6% in men aged 15-64 and 11.6% in women and 6.9% in men aged 65 and over. Nulliparous women had a lower prevalence than those who had had one, two, or three babies, but within the parity range of one to three there were no differences in prevalence. The prevalence was appreciably increased in women who had had four or more babies. Incontinence was moderate or severe in a fifth of those who reported it in the postal survey, of whom less than a third were receiving health or social services for the condition. Incontinence is a common symptom, and many unrecognised cases appear to exist. There may be considerable scope for improving its management.
The purpose of this study was to examine the effects of combining behavioral treatment and drug treatment for urge incontinence in community-dwelling older women.
Modified crossover design (extension of a randomized clinical trial). Eligible subjects were stratified according to type and severity of incontinence and randomized to behavioral treatment, drug treatment, or a control condition (placebo). Subjects not totally continent or not satisfied after 8 weeks of a single treatment were offered the opportunity to cross over into combined therapy.
A university-based outpatient geriatric medicine clinic.
Subjects in the clinical trial were 197 ambulatory, nondemented, community-dwelling women (age 55 years or older) with persistent urge urinary incontinence. Thirty-five subjects participated in combined treatment.
One group of subjects received four sessions (over 8 weeks) of biofeedback-assisted behavioral training followed by 8 weeks of behavioral training combined with drug therapy (oxybutynin chloride individually titrated from 2.5 mg to 15 mg daily). The second group received drug therapy first, followed by 8 weeks of drug therapy combined with behavioral training.
Bladder diaries completed by subjects before and after each treatment phase were used to calculate change in the frequency of incontinent episodes.
Eight subjects (12.7%) crossed from behavioral treatment alone to combined behavioral and drug therapy. Additional benefit was seen in improvement from a mean 57.5% reduction of incontinence with single therapy to a mean 88.5% reduction of incontinence with combined therapy (P = .034). Twenty-seven subjects (41.5%) crossed from drug therapy alone to combined drug and behavioral treatment. They also showed additional improvement, from a mean 72.7% reduction of incontinence with single therapy to a mean 84.3% reduction of incontinence with combined therapy (P = .001).
This study shows that combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.
This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider.
A randomized, prospective controlled trial involving 41 primary care sites.
Primary care practice sites.
49 older adults age 60 and older not previously screened for UI by their primary care doctor.
Demographic data, self-reported bladder-control information using questionnaires, and health status.
Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%).
Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.
National audit provides a basis for establishing performance against national standards, benchmarking against other service providers and improving standards of care. For effective audit, clinical indicators are required that are valid, feasible to apply and reliable. This study describes the methods used to develop clinical indicators of continence care in preparation for a national audit.
To describe the methods used to develop and test clinical indicators of continence care with regard to validity, feasibility and reliability.
A multidisciplinary working group developed clinical indicators that measured the structure, process and outcome of care as well as case-mix variables. Literature searching, consensus workshops and a Delphi process were used to develop the indicators. The indicators were tested in 15 secondary care sites, 15 primary care sites and 15 long-term care settings.
The process of development produced indicators that received a high degree of consensus within the Delphi process. Testing of the indicators demonstrated an internal reliability of 0.7 and an external reliability of 0.6. Data collection required significant investment in terms of staff time and training.
The method used produced indicators that achieved a high degree of acceptance from health care professionals. The reliability of data collection was high for this audit and was similar to the level seen in other successful national audits. Data collection for the indicators was feasible to collect, however, issues of time and staffing were identified as limitations to such data collection. The study has described a systematic method for developing clinical indicators for national audit. The indicators proved robust and reliable in primary and secondary care as well as long-term care settings.
Bladder and bowel problems are common in the elderly and are associated with a considerable morbidity and impact on quality of life. Inequalities in service provision and access to services have been recognized but there has been no systematic approach to measuring the quality of continence care for older people. This study aimed to develop quality standards, to assess the reliability and utility of the resulting audit package and to report on the standards of care provided in primary care, secondary care and care home setting.
Fifteen sites in secondary care, primary care and in long-term care settings were randomly selected to pilot the audit package. Data collectors completed audit questionnaires relating to the structure [organization] of care, the outcomes of care, and the process of care for 20 subjects with urinary incontinence and 10 subjects with faecal or double incontinence.
The audit tool was reliable (median kappa score of 0.7). Access to integrated continence services, as defined by Good Practice in Continence Services was inadequate. Eighty-five per cent of hospitals had no written policy for continence care. There were deficiencies in obtaining information, in carrying out basic and specialist examinations and investigations and in determining the cause of incontinence. There was a high prevalence of catheter use in secondary care settings.
The pilot has indicated significant inadequacies in continence care and demonstrates that in many sites the National Service Framework milestone for integrated continence services has not been met. A national audit of continence care is required to determine the extent of inadequate continence care.
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