Continence issues are rarely the reason for hospital admission. Older people who experience incontinence or constipation, or develop these issues during their stay, are at risk of poorer outcomes than those who do not.
Incontinence and constipation are often signs that an older person is experiencing other health conditions.
Targeted screening, assessment and intervention can have a positive impact on the patient’s ability to participate in all recommended activities in hospital, reduce the person’s risk of experiencing a range of cascading problems such as infection, wounds and delirium, and have a lasting effect on their social and functional quality of life when they are discharged.
Continence and ageing
As a person ages, their bladder and bowel changes, which affects their function.
Bladder changes include1:
- the elastic tissue of the bladder wall becomes tough and less stretchy and unable to hold as much urine
- weakening of the bladder muscles
- increases in involuntary bladder contractions
- urethral blockage:
- in women this can be due to weakened muscles causing the bladder or vagina to prolapse
- in men this can be due to an enlarged prostate gland
- increases in post-voiding residual volume (50–100 mL)
- increases in fluid excretion at night.
Bowel changes include2:
- sphincter weakness (for example, due to childbirth stretch injury)
- loss of anal sensation
- impairment of gastrocolic reflex
- softening of stools.
Incontinence has a big impact on health and quality of life
Incontinence has an enormous impact on an older person’s quality of life. It adds significant burden on family and carers and is a major factor in deciding to go into residential care.
Incontinence also puts people at greater risk of health issues such as falls and pressure injuries.
Incontinence has financial implications due to the cost of continence aids. It can affect a person’s general wellbeing and make them socially isolated due to embarrassment.
Continence problems can develop with other issues
In older patients, incontinence is usually caused by a combination of factors, including age-related changes to the urinary tract.
Continence problems can develop or become more severe if an older person is experiencing:
- Reduced mobility – can lead to falls when attempting to reach the bathroom. This is the single most predictive factor for incontinence, and urge incontinence has been identified as a high falls risk for men and women and as a major contributing factor to hip fractures in older women.3
- Impaired cognition – including delirium, dementia and depression, limit a person’s ability to self-toilet, particularly in an unfamiliar environment. Incontinence may add to the burden of depression.4
- Under nutrition (hydration and fibre) – adequate hydration and fibre intake is essential in maintaining bladder and bowel function. Many older people report limiting their fluids to avoid getting up to go the toilet while in hospital. This can contribute to constipation and urge incontinence.
- Medication side effects (particularly diuretics, sedatives, caffeine and alcohol) – medications can cause constipation and drowsiness, which can increase the risk of falls. Diuretics can increase frequency. Caffeine and alcohol are bladder irritants and can also increase urinary frequency.
- Skin integrity problems – exposure to urine and faeces can cause skin breakdown and leave the skin susceptible to damage from friction and pressure, dermatitis, and bacterial and fungal infections.
- Frailty – people who are frail and functionally impaired need accessible, safe toilet facilities and often benefit from assistance or supervision in hospital.
Identifying continence issues
Incontinence is rarely the reason a patient is admitted to hospital; however, it plays an important part in their recovery. Continence issues are often treatable and, in some cases, reversible.
Hospital admission presents an excellent opportunity to investigate continence issues and develop a management plan. This could improve the patient’s experience and recovery, and have lasting positive impact after discharge.
In addition to following health service policy and procedures, the following actions can help identify patients with continence issues and risks.
Screening questions
Continence is a sensitive issue. Even though we might talk about this topic with patients every day, we need to be mindful to:
- actively listen to the patient and avoid making judgements
- respect the patient’s right to choose the most appropriate treatment option.
While there are no validated screening tools available, when a person is admitted it is useful to establish their usual bowel and bladder habits. Ask these screening questions:
- Do you leak urine before you get to the toilet?
- Do you have to wear pads?
- Do you suffer from constipation or diarrhoea?
- Do your bowels or bladder ever cause you embarrassment, pain or concern?
- Are you rushing to the toilet or looking for the toilet all the time?
- Are you going to the toilet every half an hour? (in addition to leaking urine, overflow incontinence can also be identified by frequency)
- Was this an issue before you were ill or has it become worse?
If a patient answers YES to any of these questions, they should be assessed for incontinence.
If the person has a pre-existing cognitive impairment or is experiencing delirum, confirm their answers with their family or carer. If applicable, contact the patient’s residential care facility to obtain their continence plan. This information will help identify the risk of episodes of incontinence during their stay.
Assess contributing factors
As a first step, we should seek to eliminate as many contributing factors to incontinence as possible.
Use DIAPPERS to screen for reversible causes5:
- Delirium
- Infection--urinary (symptomatic)
- Atrophic urethritis and vaginitis
- Pharmaceuticals
- Psychological disorders, especially depression
- Excessive urine output (for example, from heart failure or hyperglycemia)
- Restricted mobility
- Stool impaction
Also ask about:
- decreased fluid intake
- urinary retention
- lack of toilet access
- whether the patient is emptying their bladder, especially if they have a neurological condition.
Use the Urinary Distress Inventory to check for symptoms of incontinence on admission.
Once you have identified an issue and treated underlying causes, further assessment may include physical examination, taking a brief targeted history, gathering more information on the person’s usual baseline functional abilities and using standardised tools to gather more evidence.
Take a history
A person may have a mixture of continence types, which can make the underlying cause more difficult to work out. Take a brief and targeted history, gathering the following information.
Preventing and treating incontinence
Continence interventions can reduce or minimise functional decline and promote social continence and good bladder habits and strategies.
In hospital, there are many barriers to maintaining continence and many factors contribute to incontinence. These include:
- medical factors – such as the person’s existing medical conditions, acute illness and medications
- environmental factors – such as poor signage on doors, inadequate lighting, shared bathrooms and an unfamiliar environment
- need for assistance to toilet.
We are all responsible for helping older people to maintain continence in hospital. This requires an individualised approach at the patient level, but needs to also include policy, systems and environmental design.
There are many things we can do to support continence and treat incontinence. Here are some recommendations.
Continence and discharge planning
People experiencing continence issues may have difficulty managing their continence, particularly outside the home, or feel embarrassed by their condition. They may feel reluctant to seek help due to social stigma. This can cause them to restrict their activity, increasing their risk of experiencing social isolation.7 We can help patients make a smooth transition from the hospital to their home or care facility by finding out what they understand about their condition, acknowledging their concerns, demonstrating sensitivity and developing a care plan that addresses the person’s ongoing continence management needs:13
- Do they need a referral to a continence clinic?
- Should their GP be advised of continence issues identified in hospital?
- Do they need written materials and resources to help manage continence? Refer to Continence Foundation of Australia website.
- Are they eligible for government funding support for the cost of continence aids?
- Do they need referrals for aids and specialist services?
- Would they benefit from a continence nurse follow up phone call or assessment in the community?
- Would they benefit from a referral to a dietitian for advice on maintain healthy bowels?
- Where is the person going after discharge – their own home, supported accommodation (with or without stand-up staff overnight) or residential care?
- If the person is going home, will they be alone or have help? Do they have a carer who can assist them?
- Can they afford the cost of aperients (mild laxatives) and continence appliances?
- Are they eligible for an aids assistance scheme, for example, from the Department of Veterans’ Affairs, Continence Aids Assistance Scheme or the Department of Health and Human Services’ Aids and Equipment Program?
Your organisation can develop a discharge kit that includes resources and contact details specific to your local area.
Updated