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National audit of continence care for older people: Management of faecal incontinence
Abstract
Faecal incontinence in older people is associated with considerable morbidity but is amenable to successful management. Quality standards in this area were previously subject to a pilot audit in primary, secondary care and care homes to allow providers to compare the care delivered by their service to others and to monitor the development of integrated continence services as set out in the National Service Framework for Older People. This study reports the results of the national audit.
Data were returned by 141 primary care sites, 159 secondary care trusts (involving 198 hospitals) and 29 care homes. Data on the care of 3,059 patients/residents with bowel problems were analysed. Fifty-eight per cent of Primary Care Trusts (PCTs), 48% of hospitals and 74% of care homes reported that integrated continence services existed in their areas. 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 faecal incontinence.
The results of this audit indicate that the requirement for integrated continence services contained within the National Service Framework for Older People has not yet been met. Basic assessment and care by the professionals directly looking after older persons is often lacking. There is an urgent need to re-establish the fundamentals of continence care into the daily practice of medical and nursing staff, and undoubtedly, action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.
... Only 36 papers of over 2000 publications potentially focused on aspects of service provision and were selected for further review. Twenty one were considered eligible for inclusion [9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,29,30] . Five (published across 7 publications) provided a holistic functional perspective of the evaluation and management of PFD and potential benefits of collaborative, multidisciplinary approaches in relation to both outpatient and surgical service delivery [10,11,14,17,19,22,24]. ...
... Five (published across 7 publications) provided a holistic functional perspective of the evaluation and management of PFD and potential benefits of collaborative, multidisciplinary approaches in relation to both outpatient and surgical service delivery [10,11,14,17,19,22,24]. The remainder focused on service provision in terms of just one aspect of PFD (urinary incontinence [9,12,13,15,16,18,20,21,23,25,26,27,29,30] or pelvic organ prolapse [15] . These papers tended to focus on the heterogeneity of access, appropriateness and treatment provision, service inconsistency and fragmentation, the importance of multidisciplinary team work and the need for greater service integration. ...
Pelvic floor dysfunction (PFD) has a significant socioeconomic and healthcare cost. This study aimed to investigate current service provision for PFD in the UK, highlighting any gaps and areas for improvement to inform future service improvement.
A three-phase design comprised a scoping literature review, consultation survey with frontline practitioners from four key professional groups and an overarching synthesis. An interpretative analytical framework was informed by the concepts of interdisciplinary and interprofessional collaboration.
Empirical evidence on PFD service provision is limited. No overarching strategic approach to PFD as a single clinical entity in the UK was identified. Two hundred and forty-three medical, nursing and physiotherapy practitioners from different clinical subspecialties participated in the survey. Access and availability to services, models of delivery and individual practice vary widely within and across the disciplines. Time restrictions, mixed professional attitudes, lack of standardisation and low investment priority were identified as major barriers to optimal service provision. Five overlapping areas for improvement are highlighted: access and availability, team working and collaboration, funding and investment, education, training and research, public and professional awareness.
Current services are characterised by a fragmented approach with asynchronous delivery, limited investment and poor interprofessional integration. An improved service delivery model has the potential to improve outcomes through better interdisciplinary collaboration and efficient use of resources.
... In the National Health Service in England and Wales, a centrally commissioned clinical audit programme has been established to survey the effectiveness of care for a variety of conditions. Of these projects, the National Audit of Continence Care for Older People [2, 3] has reported wide variability in the standard of care for older people with urinary and faecal incontinence and upon the considerable differences in how care is provided, despite national guidelines on service provision. These guidelines promoted the concept of integrated continence services which were to be comprehensive and cohesive; covering both urinary and faecal incontinence for the whole population, regardless of age or place of residence and which allowed ease of access and no barriers to interagency referral [4]. ...
... Organisational climate can be defined in terms of a team's perceptions of organisational policies, practices and proce- dures [8], all factors covered by the organisational audit, though to what extent the perception of the service might have influenced the responses received is unknown. Health care providers with an integrated service [3] appear to provide higher quality care to older people. Similar results have been shown in stroke and cardiac conditions [9]. ...
systematic collection of clinical outcome data remains the most difficult task in the measurement of clinical effectiveness. However, the examination of the relationship between organisational and clinical process of care may provide a surrogate measure of quality in care.
data from the 2006 National Audit of Continence Care for Older People were used to examine whether there was an association between organisational structure and standard of continence care for older people. 'Quality' scores were produced and the relationship between scores was examined.
there were statistically significant correlations between organisational and process scores for continence care. Primary care scored higher than hospitals or care homes in regard to service organisation [median (IQR): 57 (45-68) vs 48 (36-65) vs 50 (38-55), P = 0.001]. Differences were less with clinical process scores for urinary incontinence (UI) [median (IQR): 42 (32-52) vs 40 (29-49) vs 43 (34-52), P = 0.06] and for faecal incontinence (FI) [median: 42 (34-53) vs 45 (36-55) vs 47 (41-53), P = 0.12].
those with an integrated service provide higher quality care to older people. The provision of high-quality care for continence appears to be dependent upon well-organised services with personnel who have the appropriate training and skills to deliver the care.
... Although incontinence is recognised as a typical feature of advanced dementia, the majority of PLWD admitted to acute hospital wards with an unrelated condition are usually in the early and moderate stages of the disease, and thus, incontinence should not be a typical feature of their dementia [18]. Yet national acute audits conducted in the UK consistently identify PLWD and patients over 65 as being at high risk of being classified as incontinent and of receiving particularly poor continence care during acute admissions [19][20][21]. ...
Background
People living with dementia (PLWD) are at significant risk of developing urinary and/or faecal incontinence and are also at risk of functional incontinence or being labelled as being incontinent. Despite the growing population of PLWD and importance of continence care, little is known about the appropriate management, organisation, and interactional strategies for PLWD admitted to acute hospitals. This mixed methods systematic review and thematic synthesis sought to identify successful strategies across all care settings that could then be used to inform innovations in continence care for PLWD in the acute hospital setting.
Methods
In phase 1, a scoping search of two electronic databases (MEDLINE and PsycINFO) and a consultation with stakeholders was undertaken. Findings were presented to the project steering group and two priority areas for phase 2 were identified which were communication and individualised care plans. In phase 2, eight databases and relevant UK government and other organisational websites were searched for English language citations from inception to August 2020. Critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT Version 11). Thematic synthesis was employed and the strength of synthesised findings for the intervention studies was assessed using the GRADE approach and the confidence in synthesised qualitative and survey findings was assessed using the CERQual approach.
Results
In phase 1, 1348 citations were found and 75 included. In phase 2, 6247 citations were found, 14 research studies and 14 policy and guidance documents were included. The quality of studies varied. Material was synthesised into three overarching syntheses which were: communication this is dignified, person-centred and respectful; communication during outpatients apointments and delivering individualised continence care.
Conclusions
Recognising that PLWD are not always able to communicate their continence needs verbally is important. Incorporating interpersonal and communication skills into the context of continence care within training for those working with this patient group is crucial for continence to be maintained during an acute admission. Continence care in the acute setting should be tailored to the individual and be developed in partnership with staff and caregivers.
Trial registration
PROSPERO: CRD42018119495.
... Page 3/39 incontinence should not be a typical feature of their dementia [18]. Yet national acute audits conducted in the UK consistently identify PLWD and patients over 65 as being at high risk of being classi ed as incontinent and of receiving particularly poor continence care during acute admissions [19][20][21]. Studies have shown that a number of factors can contribute to the development of incontinence within hospital environments; including lack of appropriate signage, insu cient privacy, poor orientation, lack of toilets, and use of continence aids [22,23]. ...
Background: People living with dementia are at significant risk of developing urinary and/or faecal incontinence but are also at risk of functional incontinence or being labelled as being incontinent. Despite the growing population of PLWD and importance of continence care little is known about the appropriate management, organisation, and interactional, strategies for PLWD admitted to acute hospitals. This mixed methods narrative systematic review sought to identify successful strategies across all care settings that could then be used to inform innovations in continence care for PLWD in the acute hospital setting.
Methods: In phase 1 a scoping search of two electronic databases (MEDLINE and PSYCinfo) and a consultation with stakeholders was undertaken. Findings from were presented to the project steering and two priority areas for phase 2 were identified which were communication and individualised care plans. In phase 2 eight databases and relevant UK government and other organisational websites were searched for English language citations from inception to August 2020. Critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMA Version 11). Thematic synthesis was employed and the strength of synthesised findings for the intervention studies was assessed using the GRADE approach and the and confidence in synthesised qualitative and survey findings was assessed using the CERQual tool.
Results: In phase 1, 1348 citations were found and 75 included. In phase 2, 6247 citations were found 14 research studies and 14 policy and guidance documents were included. The quality of studies varied. Material was synthesized in order to identify the facilitators and barriers around developing communication strategies and individualised management plans in response to the continence needs of PLWD.
Conclusions: Recognising that PLWD are not always able to communicate their continence needs verbally is important. Incorporating interpersonal and communication skills into the context of continence care within training for those working with this patient group is crucial for continence to be maintained during an acute admission. Continence care in the acute setting should be tailored to the individual and be developed in partnership with staff and caregivers.
Systematic review registration: PROSPERO: CRD42018119495
... The study was applicable to all people with lower urinary tract symptoms (voiding and storage disorders), bladder and bowel dysfunction, urinary incontinence and faecal incontinence. Results from the audit of faecal incontinence [10] and those for urinary incontinence in women [11] have been reported elsewhere. Patients were suitable if aged 18 or over; sufficient time had elapsed to allow assessment and formulation of a management plan; a catheter was inserted for urinary incontinence rather than retention; and incontinence was either an old or a new complaint. ...
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.
... The NICE guideline on management of FI was published in 2007 [1] and delivered two key messages: (i) do not ignore the symptom and assume nothing can be done and (ii) symptoms can be resolved or at least improved in most patients if causes are identified and addressed through patient-focused treatment. The 2005 National Audit of Continence Care in Older People (NACC) predated this NICE guideline, but used comparable measures from the 2000 Department of Health report 'Good Practice in Continence Services' [9] and found low rates of assessment, diagnosis and treatment, with management being largely containment by pads [10]. The 2009 NACC updated the bowel indicators according to NICE and included adults aged 18+.This paper describes documented care of adults with FI against NICE recommendations as reported in the 2009 NACC, compares findings in older (65+) versus younger and benchmarks against prior audit results for older people. ...
Background: previous UK National Audits of Continence Care showed low rates of assessment and treatment of faecal incontinence (FI) in
older people.
Objective: the 2009 audit assessed adherence to the National Institute for Health and Clinical Excellence guidelines on management of
FI and compared care in older versus younger patients.
Methods: fifteen older (65+) and 15 younger (18–65) patients with FI were to be audited in hospital (inpatient or outpatient), primary
care (PC) and care home sites.
Results: data were submitted for n = 2,930 cases from 133 hospitals, n = 1,729 from 97 PC surgeries and n = 693 from 63 care homes. Bowel history was not documented in 41% older versus 24% younger patients in hospitals and 27 versus
19% in PC (both P < 0.001). In older people, there was no documented focused examination in one-third in hospitals, one-half in PC and three-quarters
in care homes. Overall, <50% had documented treatment for an identified bowel-related cause of FI. FI was frequently attributed
to co-morbidity. Few patients received copies of their treatment plan. Quality-of-life impact was poorly documented particularly
in hospitals.
Conclusions: this national audit shows deficits in documented assessment, diagnosis and treatment for adults with FI despite availability
of clinical guidance. Overall care is significantly poorer for older people. Clinicians, including geriatricians, need to
lead on improving care in older people including comprehensive assessment where needed. Improvement in some indicators in
older people with successive audits suggests that ongoing national audit with linked information resources can be useful as
both monitor and agent for change.
... The use of formal testing is hampered by both lack of relevant data from frail older people and the poor correlation between symptoms and abnormalities [971,972,977,[1034][1035][1036]. Evidence that the assessment of faecal incontinence in older people is poorly done despite the existence of guidelines has been a persistent finding throughout the history of this chapter [361,1037]. What actions need to be taken to ensure that older people receive assessments which are consistent with current guidelines remain to be defined. ...
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.AimsTo update the recommendations of the 4th ICI.Materials and MethodsA series of systematic reviews and evidence updates were performed by members of the working group in order to update the 2009 recommendations. The resulting guidelines were presented at the 2012 meeting of the European Associatioon of Urology.ResultsAlong with the revision of the treatment algorithm and accompanying text. There have been significant advances in several areas including pharmacological treatment of overactive bladder.DiscussionThe committee continue to notes the relative paucity of data concerning frail older persons and draw attention to knowledge gaps in this area. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.
... There is evidence that older adults delay seeking medical help for incontinence and that the responses of some health professionals to incontinence are sub-optimal [13][14][15][16]. In addition, older adults are less likely to receive treatment congruent with evidence-based guidelines [16][17][18][19]. The high prevalence of incontinence in people with dementia who reside in care homes is well documented [8], but international estimates suggest that over two-thirds of all people with dementia live in their own homes [20,21]. ...
Background:
Dementia is one of the most disabling and burdensome diseases. Incontinence in people with dementia is distressing, adds to carer burden, and influences decisions to relocate people to care homes. Successful and safe management of incontinence in people with dementia presents additional challenges. The aim of this study was to investigate the rates of first diagnosis in primary care of urinary and faecal incontinence among people aged 60-89 with dementia, and the use of medication or indwelling catheters for urinary incontinence.
Methods and findings:
We extracted data on 54,816 people aged 60-89 with dementia and an age-gender stratified sample of 205,795 people without dementia from 2001 to 2010 from The Health Improvement Network (THIN), a United Kingdom primary care database. THIN includes data on patients and primary care consultations but does not identify care home residents. Rate ratios were adjusted for age, sex, and co-morbidity using multilevel Poisson regression. The rates of first diagnosis per 1,000 person-years at risk (95% confidence interval) for urinary incontinence in the dementia cohort, among men and women, respectively, were 42.3 (40.9-43.8) and 33.5 (32.6-34.5). In the non-dementia cohort, the rates were 19.8 (19.4-20.3) and 18.6 (18.2-18.9). The rates of first diagnosis for faecal incontinence in the dementia cohort were 11.1 (10.4-11.9) and 10.1 (9.6-10.6). In the non-dementia cohort, the rates were 3.1 (2.9-3.3) and 3.6 (3.5-3.8). The adjusted rate ratio for first diagnosis of urinary incontinence was 3.2 (2.7-3.7) in men and 2.7 (2.3-3.2) in women, and for faecal incontinence was 6.0 (5.1-7.0) in men and 4.5 (3.8-5.2) in women. The adjusted rate ratio for pharmacological treatment of urinary incontinence was 2.2 (1.4-3.7) for both genders, and for indwelling urinary catheters was 1.6 (1.3-1.9) in men and 2.3 (1.9-2.8) in women.
Conclusions:
Compared with those without a dementia diagnosis, those with a dementia diagnosis have approximately three times the rate of diagnosis of urinary incontinence, and more than four times the rate of faecal incontinence, in UK primary care. The clinical management of urinary incontinence in people with dementia with medication and particularly the increased use of catheters is concerning and requires further investigation. Please see later in the article for the Editors' Summary.
... In a small randomized, controlled trial of the effect of computerized templates on the assessment and treatment of urinary incontinence, the intervention group had 100% compliance with the qualityofcare measures for both the history and physical examination, compared with 25% (history) and 37.5% (physical examination) compliance for the control group [36] . The control group compliance rates with history and physical examination qualityofcare measures were similar to those found in an audit of fecal incontinence care in the UK [37] . In addition, computerized medical records may make audit of qualityofcare measures (such as screening rates) and feedback to healthcare providers easier. ...
Fecal incontinence is an important health issue that has devastating psychological, social and economic consequences for the aging population. However, it is under-reported and under-treated, often because of mistaken assumptions that incontinence is a normal part of aging and that little can be done about it. There are effective treatments that can be easily implemented in the primary-care setting, which can greatly improve an older person's quality of life and potentially avert premature referral to a nursing home. Therefore, it is important that clinicians screen for the problem and are comfortable with its evaluation and treatment. This article reviews the epidemiology of fecal incontinence, approaches to improving identification and quality of care, as well as the assessment and treatment of the most common etiologies of fecal incontinence.
... Our study results are also somewhat similar to Table 3 Inter-rater reliability between holistic overall ratings of the same record by paired reviewers of different staff types 24 Criterion-based review demonstrated that all reviewers could identify relevant data (the effectiveness of reviewer scores were around 95%). There were moderate (0.61 for non-clinical audit staff) to quite high levels of inter-rater reliability (clinical staff 0.74, doctors 0.88)dsimilar to those found in large UK national clinical audit programmes of stroke 25 26 and continence, 27 and reflecting the trend to higher values for explicit reviews found in other studies. 5 Our study confirms the findings of the UK stroke care audit, 25 26 that criterion-based record review can be undertaken by staff from different backgrounds. ...
To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care.
Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale.
Nine randomly selected acute hospitals in England.
Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. ANALYSIS METHODS: Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison.
A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods.
Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.
... The levels of inter-rater reliability for criterionbased review ranged from moderate (0.61 for nonclinical audit staff) to quite high (clinical staff 0.74, doctors 0.88), and are similar to those found in the large UK national clinical audit programmes of stroke care 24,25 and continence care. 42 All three staff types performed equally well at capturing criterionbased data from records, despite differences in their backgrounds, again confirming the findings of the UK stroke care audit. 24,25 It is unsurprising that criterion-based review has higher levels of inter-rater reliability than holistic review, as the criteria are predetermined, directly evidence based, have been subject to peer review and are explicit rather than implicit. ...
Objectives:
To determine which of two methods of case note review--holistic (implicit) and criterion-based (explicit)--provides the most useful and reliable information for quality and safety of care, and the level of agreement within and between groups of health-care professionals when they use the two methods to review the same record. To explore the process-outcome relationship between holistic and criterion-based quality-of-care measures and hospital-level outcome indicators.
Data sources:
Case notes of patients at randomly selected hospitals in England.
Review methods:
In the first part of the study, retrospective multiple reviews of 684 case notes were undertaken at nine acute hospitals using both holistic and criterion-based review methods. Quality-of-care measures included evidence-based review criteria and a quality-of-care rating scale. Textual commentary on the quality of care was provided as a component of holistic review. Review teams comprised combinations of: doctors (n = 16), specialist nurses (n = 10) and clinically trained audit staff (n = 3) and non-clinical audit staff (n = 9). In the second part of the study, process (quality and safety) of care data were collected from the case notes of 1565 people with either chronic obstructive pulmonary disease (COPD) or heart failure in 20 hospitals. Doctors collected criterion-based data from case notes and used implicit review methods to derive textual comments on the quality of care provided and score the care overall. Data were analysed for intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs) and completeness of criterion data capture, and comparisons were made within and between staff groups and between review methods. To explore the process-outcome relationship, a range of publicly available health-care indicator data were used as proxy outcomes in a multilevel analysis.
Results:
Overall, 1473 holistic and 1389 criterion-based reviews were undertaken in the first part of the study. When same staff-type reviewer pairs/groups reviewed the same record, holistic scale score inter-rater reliability was moderate within each of the three staff groups [intraclass correlation coefficient (ICC) 0.46-0.52], and inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61-0.88). When different staff-type pairs/groups reviewed the same record, agreement between the reviewer pairs/groups was weak to moderate for overall care (ICC 0.24-0.43). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement (p-values for difference 0.406 and 0.223, respectively), although results from all three staff types showed no overall level of agreement (p-value for difference 0.057). Detailed qualitative analysis of the textual data indicated that the three staff types tended to provide different forms of commentary on quality of care, although there was some overlap between some groups. In the process-outcome study there generally were high criterion-based scores for all hospitals, whereas there was more interhospital variation between the holistic review overall scale scores. Textual commentary on the quality of care verified the holistic scale scores. Differences among hospitals with regard to the relationship between mortality and quality of care were not statistically significant.
Conclusions:
Using the holistic approach, the three groups of staff appeared to interpret the recorded care differently when they each reviewed the same record. When the same clinical record was reviewed by doctors and non-clinical audit staff, there was no significant difference between the assessments of quality of care generated by the two groups. All three staff groups performed reasonably well when using criterion-based review, although the quality and type of information provided by doctors was of greater value. Therefore, when measuring quality of care from case notes, consideration needs to be given to the method of review, the type of staff undertaking the review, and the methods of analysis available to the review team. Review can be enhanced using a combination of both criterion-based and structured holistic methods with textual commentary, and variation in quality of care can best be identified from a combination of holistic scale scores and textual data review.
... 10,20,21 However, poor quality information was collected on cognitive impairment within community care assessments 2 and assessments of toileting and incontinence were often cursory. 52 Our study showed that the identification of these conditions had improved since the introduction of the SAP. One way of achieving this may have been through the closer involvement of specialist clinicians in social services decision making through their 'specialist' contribution to assessments as part of the SAP. ...
The single assessment process (SAP) for older people, introduced in England across health and social care agencies from April 2004, aimed at improving assessment processes. We examined the impact of this policy in terms of the reliability of needs identification within statutory social services assessments.
An observational study compared the accuracy of needs identification in samples of older people before and after SAP introduction. Participants, at risk of entering care homes, were interviewed using standardized measures. Needs elicited from interviews were compared with those from statutory social services assessments to ascertain the reliability of needs identification at both times. Inter-rater reliabilities were calculated using the kappa (k) statistic. A Chi-squared statistic tested the equality of kappa values pre- and post-SAP.
Most needs were identified more reliably after SAP introduction (range adjusted k = 0.05-0.58) than before (range adjusted k = -0.09 to 0.28), this being statistically significant for 9 out of 15 needs. Depression, and associated apathy, was an exception.
Statutory social services assessments better captured need following the introduction of the SAP. However, the extent to which these findings can be attributed to SAP introduction is limited by the introduction of multiple policy initiatives throughout the study period.
Background
Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.
Objective
To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.
Design
A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.
Data sources
The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.
Results
The scoping identified six programme theories with related context–mechanism–outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals’ preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.
Limitations
The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.
Conclusions
This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.
Future work
Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.
Study registration
This study is registered as PROSPERO CRD42014009902.
Funding
The National Institute for Health Research Health Technology Assessment programme.
The prevalence of fecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. Using realist synthesis, 6 potential program theories of what should work were identified. These addressed clinician-led support, assessment, and review; the contribution of teaching and support for care home staff on how to reduce and manage FI; addressing the causes and prevention of constipation; how cognitive and physical capacity of the resident affects outcomes; how the potential for recovery, reduction, and management of FI is understood by those involved; and how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Dementia was a known risk factor for fecal incontinence (FI), but how it affected uptake of different interventions or the dementia specific continence and toileting skills staff require, were not addressed in the literature. There was a lack of dementia-specific evidence on continence aids. Most care home residents with FI will be doubly incontinent; there is, therefore, limited value in focusing solely on FI or single causes, such as constipation. Medical and nursing support for continence care is an important resource, but it is unhelpful to create a distinction between what is continence care and what is personal or intimate care. Prompted toileting is an approach that may be particularly beneficial for some residents. Valuing the intimate and personal care work unqualified and junior staff provide to people living with dementia and reinforcement of good practice in ways that are meaningful to this workforce are important clinician-led activities. Providing dementia-sensitive continence care within the daily work routines of care homes is key to helping to reduce and manage FI for this population. © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine
Continence is complex and relies on a number of factors. Incontinence is a complex problem with many possible causes, some are very common and others seen less frequently. Presentations and symptoms may be multifactorial, requiring a dynamic person-centred approach to assessment and treatment. The possible causes of bowel incontinence relating to age, traumatic injuries and medical conditions are discussed in detail.
Faecal incontinence is a disabling and distressing condition that affects all age groups. It is more common in women than men, with the highest prevalence being among the elderly. It has been estimated to affect 1-2% of the population over 40 years of age [1, 37, 38]. Faecal incontinence is associated with considerable morbidity, especially in the elderly, but is amenable to successful management. Despite this there is recent evidence to show that basic assessment and care are lacking [21] and could be improved.
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.
Currently a gulf exists between the care frail older people receive and that which they need. In order to create services that can meet complex needs we require doctors who appreciate the specific challenges elders face. There is a need to develop educational programmes that focus on the complexities of real life practice and the commonly encountered challenges faced when caring for older adults. Early exposure to complex frail older people and experiences that challenge negative attitudes are important. Most care delivered to older people is delivered by non-geriatricians, and thus geriatricians have an important role in training. Training should be available for trainers as well as trainees!
Faecal incontinence in older people is a distressing and socially isolating symptom and increases the risk of morbidity, mortality and dependency. Many older individuals with faecal incontinence will not volunteer the problem to their general practitioner or nurse and, regrettably, health care providers do not routinely enquire about the symptom. Even when older people are noted by health care professionals to have faecal incontinence, the condition is often managed passively, especially in the long-term care setting where it is most prevalent. The importance of identifying treatable causes of faecal incontinence in older people, rather than just managing passively, is strongly emphasized in national and international guidance, but audit shows that adherence to such guidance is generally poor. This article describes epidemiology, causes, assessment, diagnosis and treatment of faecal incontinence in older people.
Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years.
Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively.
Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6).
SNS is an effective treatment for faecal incontinence in patients over 65 years.
This is a review of descriptive studies with incontinence as the primary focus in older people in care homes.
Incontinence is prevalent among residents of care home populations.
MEDLINE and CINAHL were searched from 1996 to 2007 using the highly sensitive search strings of the Cochrane Incontinence Review Group for urinary and faecal incontinence including all research designs. Search strings were modified to enhance selectiveness for care homes and older people and exclude studies involving surgical or pharmacological interventions. Searching of reference sections from identified studies was also used to supplement electronic searches. The Cochrane Library was searched for relevant systematic reviews to locate relevant studies from those included or excluded from reviews. The search was limited to English-language publications.
A systematic review of studies on the management of incontinence, promotion of continence or maintenance of continence in care homes was conducted in 2007-2009. This is a report of descriptive studies. Results. Ten studies were identified that reported on prevalence and incidence of incontinence (urinary with or without faecal), policies, assessment, documentation, management or economic evaluation of its management. Use of incontinence pads and toileting programmes comprised the most common management approaches used. No studies were identified that attempted to maintain continence of residents in care homes.
Studies on maintaining continence and identifying components of toileting programmes that are successful in managing or preventing incontinence and promoting continence in residents of care home populations along with their economic evaluation are warranted.
Urinary urgency with incontinence, and fecal incontinence and constipation were followed up over a 6-year period in 398 subjects aged 70 years and over at baseline. Age- and gender-adjusted and multivariate Cox proportional hazard models were used to examine the associations of urinary urgency and fecal incontinence and constipation with mortality, and logistic regression models to determine predictors of incident symptoms among the survivors. The proportion of incident cases of urinary urgency with incontinence, fecal incontinence and constipation in the 252 survivors were 17% (n=46), 9% (n=34) and 13% (n=36), respectively. Frequently reported urinary urgency (hazard ratio, HR=2.23; 95% confidence interval, CI=1.37-3.61) and frequently reported fecal incontinence (HR=4.99; CI=2.11-11.79) were associated with mortality when adjusted for age and gender only. In the multivariate analyses, comorbidity (odds ratio, OR=5.54; CI=2.03-15.14), depressive mood (OR=5.78; CI=1.35-24.79) and instrumental activities of daily living (IADL) disability (OR=4.18, CI=1.52-11.50) predicted incident urgency urinary incontinence. Comorbidity (OR=2.91; CI=1.09-7.77) predicted incident fecal incontinence, while no significant predictors were identified for the incident symptom of constipation. Comorbidities and disabilities explain the association of severe urinary and fecal incontinence with mortality.
Falls in older people constitute a common health hazard, which has attracted much attention and research. There are many evidence-based interventions, which have been shown to reduce the subsequent risk of falls. There is good evidence for an association between the risk of falling and the presence of urinary incontinence in older people, but incontinence has not been routinely included in interventions targeted to reduce falls. This article reviews the evidence for current falls intervention and the association between falls and urinary incontinence, making the case for an intervention study.
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.
This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE).
DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated.
The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for.
Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.
Seventeen per cent of people over the age of 65 and 80% of people in care homes are constipated. Approximately 3-10% of older people in the community have faecal incontinence. Careful attention to assessment, based on an understanding of pathophysiology, will provide an explanation for bowel dysfunction. The causes are often multiple and may relate to local bowel pathology, systemic disease, complications of medication or functional disability. The possibility of underlying serious bowel disease must be borne in mind. Management should be directed to correcting the underlying causes. Laxatives, suppositories and enema use should be determined by the presence or absence of delayed transit and difficulty in evacuation. In the presence of dementia, a clear understanding of the physical and psychological disturbances present must be established to enable an effective management plan. Particular attention should be paid to the environment to promote privacy, comfort and dignity, as well as to enhance normal bowel function.
Purpose: This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE). Design and Methods: DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated. Results: The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for. Implications: Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.
Objective: to examine the relationship between incontinence and mortality in elderly people living at home. Design: of the randomly selected people aged 65 years and older living in Settsu city, Osaka in October 1992, 1405 were contacted and constituted the study cohort. Follow-up for 42 months was completed for 1318 (93.8%; 1129 alive, 189 dead). Measures: data on general health status, history of health management, psychosocial conditions and urinary and faecal incontinence were collected by interview during home visits at the time of enrolment. Results: from the Kaplan‐Meier analysis, the estimated survival rates decreased with a decline in continence in both the 65‐74 and 75 years and older age groups. From the Cox proportional hazards model, unadjusted hazard ratios of minor, moderate and severe incontinence for mortality, compared with continence, were 2.27, 2.96 and 5.94, respectively. Multivariate analysis yielded adjusted hazard ratios of minor, moderate and severe incontinence of 0.99, 1.17 and 1.91, respectively, leaving severe incontinence as the significant factor, when other indicators are controlled. Conclusions: incontinence is related to mortality and severe incontinence represents an increased risk factor for mortality in elderly people living at home.
Even though fecal incontinence is a leading cause of nursing home placement, risk factors contributing to its development have not been established. Identification of such factors may lead to prevention of incontinence and reduce the need for nursing home placement. A total of 388 residents of five nursing homes were included. Data regarding mental status, bowel habits, obstetrics history, and the presence, frequency, and severity of fecal incontinence were collected for each participant. Of the 388 nursing home residents, 46% were incontinent of feces. Incontinence was 1.5 times more common in males and in those younger than 65 years of age. In both univariate and multivariate analyses, diarrhea, dementia, restricted mobility, and male gender were independently associated with incontinence. In contrast to previous studies, constipation was not associated with fecal incontinence. If elimination of these risk factors leads to prevention of incontinence in even a few people, some elderly patients may not require institutionalization, which will result in improvement in their quality of life, not to mention a reduction in public health expenditures.
This study was conducted to evaluate the incidence, identify the risk factors, and assess the prognosis of elderly institutionalized patients who develop fecal incontinence.
We enrolled 1,186 patients 60 years of age and older living in long-term care facilities who did not have fecal incontinence. We assessed their medical history, treatment, mobility, and cognitive function. Patients were followed up for 10 months to determine the incidence of fecal incontinence, defined as at least one involuntary loss of feces. Independent risk factors associated with fecal incontinence were identified using Cox proportional hazards models. The prognosis of incontinent patients was assessed by comparing their survival rate with that in the continent patients.
Fecal incontinence occurred in 234 patients (20%), and was usually associated with acute diarrhea or fecal impaction. We identified five risk factors for the development of fecal incontinence: a history of urinary incontinence (rate ratio [RR]: 2.0, 95% confidence interval [CI] 1.5 to 2.6); neurological disease (RR: 1.9, 95% CI 1.0 to 3.4); poor mobility (RR: 1.7, 95% CI 1.2 to 2.4); severe cognitive decline (RR: 1.4, 95% CI 1.1 to 1.9); and age older than 70 years (RR: 1.7, 95% CI 1.0 to 2.8). Ten-month mortality in the 89 patients with long-term (> or = 8 days) incontinence was 26%, significantly greater than that observed in the continent group (6.7%) or in the 145 patients with transient incontinence (10%).
Long-lasting or permanent fecal incontinence was associated with increased mortality, suggesting that this symptom is a marker of poor health in older patients. Actions that improve mobility might help prevent fecal incontinence in elderly patients.
To examine the relationship between incontinence and mortality in elderly people living at home.
Of the randomly selected people aged 65 years and older living in Settsu city, Osaka in October 1992, 1405 were contacted and constituted the study cohort. Follow-up for 42 months was completed for 1318 (93.8%; 1129 alive, 189 dead).
Data on general health status, history of health management, psychosocial conditions and urinary and faecal incontinence were collected by interview during home visits at the time of enrolment.
From the Kaplan-Meier analysis, the estimated survival rates decreased with a decline in continence in both the 65-74 and 75 years and older age groups. From the Cox proportional hazards model, unadjusted hazard ratios of minor, moderate and severe incontinence for mortality, compared with continence, were 2.27, 2.96 and 5.94, respectively. Multivariate analysis yielded adjusted hazard ratios of minor, moderate and severe incontinence of 0.99, 1.17 and 1.91, respectively, leaving severe incontinence as the significant factor, when other indicators are controlled.
Incontinence is related to mortality and severe incontinence represents an increased risk factor for mortality in elderly people living at home.
faecal incontinence affects quality of life and causes caregiver strain. Patients are often reluctant to seek help because of embarrassment and perceived lack of effective treatment. Persisting faecal soiling may lead to unwanted and premature institutionalization.
to ascertain the prevalence of faecal incontinence and to identify health and socio-demographic characteristics of patients with this problem.
a sample of 3000 older people, living at home in the UK, randomly selected from three Family Health Service Authorities.
we interviewed 2818 men and women aged > or =65 years in their own homes: a response rate of 94%.
78 respondents (3%) reported faecal incontinence. There was a small but non-significant association with increasing age: 38 (2%) of those reporting incontinence were aged 65-74 years; 40 (3%) were aged > or =75 years. Faecal incontinence was significantly associated with sex, with reports from 15 men (1%) versus 63 women (4%; P<0.0005). It was also significantly associated with anxiety and with depression (P<0.00001) and very significantly associated with increasing disability (P<0.00001). Forty-six (59%) of those who had faecal incontinence had severe disability, compared with 426 (16%) of those who did not (P<0.00001). The association with urinary incontinence was also strong: 54 (69%) of those with faecal incontinence (2% of the total sample) had coexistent urinary incontinence. Over 50% had not discussed their problems with a healthcare professional.
a reluctance to report symptoms and a significant association between faecal incontinence and symptoms of anxiety, depression and disability suggest that older people should be asked about faecal incontinence. Increasing the awareness of the scale of the problem among health- and social-care professionals, older people and their carers may lead to more appropriate management and effective provision of care.
The self-reported bowel habits and the prevalence of faecal incontinence and constipation in men and women between the ages of 31 and 76 are assessed.
A postal questionnaire was sent to a random sample (n = 2000) of the total population of persons between the ages of 31 and 76 living in the County of Ostergötland, Sweden.
The response rate was 80.5%. Overall, 67.8% reported one bowel movement per day and 4.4% had more than 21 or less than 3 bowel movements per week. This means that 95.6% had between 3 bowel movements a day to 3 bowel movements a week. Among women, 4.3%, and among men. 1.7%, reported less than 3 bowel movements per week. Women and men used the same terms to describe the definition of constipation. Women had a significantly higher self-reported prevalence of constipation than men (P < 0.0001). About 20% of all women considered themselves constipated. The use of laxatives increased with age and 22% and 10% of elderly women and men, respectively, used laxatives including bulking agents for at least every fourth toilet procedure. About 10% reported leakage of faeces more often than once a month in the case of loose stools. With solid faeces, the rate of leakage was 1.4% and 0.4% for women and men, respectively. Soiling of underclothes more than once a month occurred in 21% of men and in 14.5% of women (P = 0.006) and involuntary daily leakage of gas in 5.9% of men and 4.9% of women (n.s.).
Constipation and faecal incontinence are common problems in a general Swedish population.
Faecal incontinence occurs in up to 10% of community dwelling persons ≥65 years of age and approximately 50% of nursing home residents. It is a vastly under-reported problem that has a devastating effect on those who experience it as well as their spouses and caregivers.
There are three broad categories of faecal incontinence among the elderly: (i) overflow incontinence; (ii) reservoir incontinence; and (iii) rectosphincteric incontinence. The first two can be diagnosed based upon the patient’s history and physical examination and the response to dietary and pharmacological interventions. The third is assessed by careful physical examination supplemented by diagnostic tests directed towards evaluation of anorectal continence mechanisms. The most important of these is anorectal manometry, which can be supplemented by studies of structure (anal ultrasonography or pelvic floor magnetic resonance imaging) and neuromuscular function (electromyogram). A variety of therapeutic interventions are employed in patients with rectosphincteric incontinence; these include dietary, behavioural, pharmacological and surgical modalities chosen on the basis of the results of diagnostic testing. For isolated internal anal sphincter weakness, a cotton barrier in the anal canal is often effective. Acute sphincter injury is best treated with sphincteroplasty but, otherwise, surgical procedures are of uncertain benefit. Peripheral neurogenic incontinence may be treated with antidiarrhoeal agents, biofeedback techniques and dietary manipulations. Sacral spinal nerve stimulation is a promising new technique for selected patients with neurogenic faecal incontinence and is currently undergoing testing in the US and Europe. Significant improvement in quality of life can be achieved in most elderly persons with faecal incontinence.
Faecal incontinence is a problem that can have a major impact on the quality of life of those affected. Our aim was to relate the severity of faecal incontinence to the impact on several general health domains.
Patients from a prospective diagnostic cohort study, performed in 16 medical centres in the Netherlands, were invited to the study. The severity of incontinence was determined with the Vaizey score, which ranges from 0 (continent) to 24 (totally incontinent). Based on their Vaizey score, patients were assigned to one of five severity categories. All patients completed the EuroQol-5D instrument, which evaluates the existence of problems on five health domains: mobility, self-care, usual activities, pain/discomfort and anxiety/depression.
Data from 259 consecutive patients (25 male) could be analysed. Their mean age was 59 years (SD +/- 12). The mean duration of faecal incontinence was 8.1 years (SD +/- 8). The proportion of patients reporting problems rose significantly with increasing severity of faecal incontinence in the domains of usual activities (ranging from 36% in the least severe group to 71% in the most severe group (P < 0.001)), pain/discomfort (ranging from 35% to 60%; P = 0.025), and anxiety/depression (ranging from 23% to 49%; P = 0.037). No significant trends could be observed in the domains of mobility and self-care.
There exists a significant relation between severity of incontinence and frequency of reported problems in the domains of usual activities, pain/discomfort and anxiety/depression.
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.
To investigate the prevalence of anal incontinence in the general population and in patients consulting gastroenterologist and gynecologist practices in the Rhône Alpes area.
For the first study a questionnaire was sent to a sample of 2800 people selected randomly from the electoral roll. Another study of patients selected randomly among patients attending gynecology and gastroenterology consultations was performed. A Jorge & Wexner score above or equal to 5 was used to define anal incontinence.
For the first study, a total of 706 questionnaires was analyzed: the prevalence of anal incontinence was 5.1% [95% CI: 3.6-7.0] and the scores of each dimension of the SF-12 Health Survey were significantly lower among incontinent people than among continent people. The prevalence was significantly higher for women (7.5% [5.0-10.7]) than for men (2.4% [1.1-4.7]). Eighty-four physicians returned 835 valid questionnaires. The prevalence was 13.1% [10.1-16.6] among patients attending gastroenterology consultations and 5.0% [3.1-7.6] among those attending gynecology consultations. For 84.8% of the incontinent patients, the physician was unaware of the patient's disorder.
The prevalence figures we obtained coincide with data in the literature. This disorder is common and affects the patient's quality-of-life, but remains underestimated and under-diagnosed.
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