Continence Strategies: Towards Independence in the Elderly

Karina SoClinical Nurse Consultant

Urology / Continence ManagementConcord Hospital

Practical strategies

• Curative therapy for mild SI• Symptom management for SI & UI• Containment for severe and permanent

Urinary incontinence • Nocturnal incontinence• Risk management on IDC/SPC/CISCUrge incontinence is associated with a

modest increase in falls.Chiarelli et. Al.(2008) Urinary incontinence is associated with an increase in falls: a systematic review” Australia

Journal of Physiotherapy 55: 89-95

Common Continence Problems in the elderly population

• Stress incontinence (SI)

• Urge incontinence (UI)

• Mixed incontinence

• Overflow incontinence

• Functional incontinence

Drugs that can cause urinary incontinenceAgent Mechanism of Action Type of Incontinence

AntihypertensivePrazosin, Labetolol Sphincter relaxation

Stress Incontinence

Bladder relaxantAnticholinergics

Tricyclic Antidepressants

Promote incomplete emptying

Overflow

Incontinence

Bladder StimulantCaffeine, Cholinergics

Enhance detrusor instability

Urge Incontinence

SedativeAntihistamines,antidepressants antipsychotics,Tranquilisers, Hypnotics

Reduce awareness of bladder sensation

Urge incontinence

Miscellaneous Alcohol

loop diuretics

Lithium

Lower inhibition

Increase bladder filling, Polydipsia

Urge incontinence

Stress Incontinence (SI)• Mild SI - Curative therapy

– Pelvic Floor Muscle Exercises– Behavioural modification– Review medication(s)– Healthy diet & maintain healthy wt.– Regulate fluid intake & healthy bowel habit

Real-time Ultrasound Scan

• Patient can watch pelvic floor muscles contract and relax as you retrain them (visual feedback on performance).

• It is a tool to encourage compliance.

• It does not measure PFM strength.

Moderate SI

Symptom management– Mild SI care path– Intravaginal device – pessary ring,

tampon, Contiform device.– Selection of continence products

uridome

Symptom management SI

• Contiform!

• Penile clamp should be released every one to two hours to empty the bladder and prevent damage.

Severe and permanent SI

Supportive care/ Risk Management – Containment– Social continence– Prevent skin problems, UTIs, odour control– Government Continence Aids schemes

• PADP • CAAS/CAPS• DVA – gold card

Management of Urge Incontinence

• Regulate fluid intake:amount,type, time.• Bladder training strategies +/- medication• Clothing- reduce layers, zipper/belt• Medications – dose, time, route.• Healthy diet, healthy bowel.• Selection of appropriate continence aids• Assess eligibility for Government

schemes:PADP / CAAS/ DVA

Bladder Training therapyFor mild-moderate sensory and motor

urgency.

• Deferment strategies (take control)– Pelvic floor muscle contractions– Talk to your bladder– Tactile sensation/pressure– Distraction (think hard)

• Identify Optimal voiding time

• Frequency, volume & urgency diary

Drugs used to treat OABAnticholinergics/Antimuscurinic

• Propantheline (Pro-banthine 15 - 30mg q.i.d.)

• Oxybutynin (Ditropan 5mg up to q.i.d.)– Oxytrol transdermal patch (3.9mg twice a week)

• Tolterodine (Detrusitol 1 - 2mg b.i.d.)

• Darifenacin (Enablex)

• Solifenacin (Vesicare 5 – 10mg daily)

Travel or bed time companion

Nocturnal incontinence

Booster padPull up pants

Stricture therapy – patient specific

• Identify the optimal time for urethral dilatation before a reduction in urine flow.

• Select the size and type of firm catheter.

• Educate and support patient to perform regular self dilatation.

Coude tip firm nelaton catheter

Management of Acute Urinary Retention

• Decompress the bladder using 100% silicone catheter size 14/16

• Select the most appropriate drainage device – bag / valve

• Educate patient & carer on IDC care

Catheter size Balloon Size

12 FG

14 FG

16 FG

18 FG

20 FG

22 FG

24 FG

• 3 ml• 5 ml• 10 ml• 20 ml• 30 ml• 60 ml

Colour code

Catheter valve & leg bag

Management of Chronic Urinary Retention

• Prevent recurrent symptomatic UTI• Identify high risk cases for urosepsis and prepare

care plan– Use antibacterial soap for daily hygiene– If possible, high fluid intake > 2 litre/day– Prevent and correct constipation– Avoid trauma during catheter replacement procedure– Use catheter fixation device to avoid traction– Frequency of IDC or SPC replacement is individualised.– Periodic Urology review

Neurogenic bladder

CISC +/-

Anticholinergic

Medication

Queen Square Bladder Stimulator $75

Management of CISC• Reduce Symptomatic UTI –

assess CISC technique,

frequency of CISC, equipment care,

single use versus reusable catheter.

• Educate patient on monitoring of residual volume – bladder diary.

• Periodic urology review.

Class of laxatives/time to effect

Bulk forming agents Oral, 48-72 hrs.

Osmotic agents

(sorbitol, lactulose,glyerol)

Oral, 24-72 hrs.

Osmotic agents

(Macrogol or saline laxatives)

Oral, 0.5 – 3 hrs.

Stool softeners Oral, 24 -72 hrs.

Stimulant Oral, 6- 12 hrs.

Government Continence Aids Schemes

• NSW Health – Enable Health– PADP

• Federal Government Schemes – CAAS– CAPS from July 2010– DVA for veterans with gold card

PADP Transition to Enable Health

• Website: www.health.nsw.gov.au/health-public-affairs/factsheets

• One centralised body

• Office is based in Parramatta

• Transfer of PADP data in stages

Continence Aids Assistance Scheme (CAAS)

• CAAS is an Australian Government scheme offering assistance to eligible people who have permanent and severe incontinence.

• The scheme covers children aged 5 to 15 years, and adults over 64 years with permanent incontinence due to neurological conditions (Cat.A).

• The scheme also includes all causes of permanent incontinence, not just neurological causes, for those people who hold a pensioner concession card and their dependents (Cat.B).

• Website: www.intouchdirect.com.au

• The National Continence Helpline 1800 330 066

Continence Aids Payment Scheme (CAPS)

As of July 2010 …..• Clients can receive a one off payment of up

to $489.95 to purchase their own products.• Can nominate the payment goes to an

agency/ supplier.• CAPS payment is exempted as income.• Contact Medicare Australia Office for

information 132 011

Role of Medicare Australia

As of July 2010..• Respond to enquires about CAPS.• Receive and process CAPS applications.• Make payments directly into a CAPS client’s

nominated bank account or nominated provider’s account.

• Send statements regarding the payment to clients.

• Supply CAPS Application form