老人尿失禁的照護技巧老人尿失禁的照護技巧The Techniques of Caring the The Techniques of Caring the

Aging with Urinary Aging with Urinary IncontinenceIncontinence

王炯珵恩主公醫院泌尿科

Chung Cheng WangDepartment of Urology En Chu Kong Hospital

State of the Science on State of the Science on Urinary IncontinenceUrinary Incontinence

Nurses have in their toolboxes some help for first-line UI intervention and screening [Diane Newman, 2002 July]

The first priority is to increase awareness among nurses. [Mary Palmer, 2003AJN]

Noninvasive behavioral interventions can be effective in long-term care setting

But staff compliance was problematic [Palmer MH 1997]

EpidemiologyEpidemiology

20 million American have UI [Abram P 2002]

22% of women aged 65 and older had UI in daily life [Tseng 2000]

More than 50% of nursing home residents [Fantl J,1996]

Differences in GenderDifferences in Gender

Female: male = 2:1 [Hunskaar S 2001]

stress or mixed UI: female Pure urge UI: equal Postvoid dribbling, nocturnal enuresis: male

[Temml C 2000]

Women were more likely to regularly use strategies for UI management [Johnson TM 2000]

Risk Factors in WomenRisk Factors in Women

Gravidity and parity One vaginal birth: 2.5 times for UI [Nygaard IE 1994]

Breech presentation, use of forceps, tearing, central episiotomy, oxytocin

Pelvic organ prolapse Gynecologic surgery Menopause Obesity [Roe B 1999]

Risk Factors in MenRisk Factors in Men

A history of radical or transurethral prostatectomy [Umlauf 1996]

The first year of admission to a long-term care facility [Palmer MH 1991]

Causes of urge UI in elderly men: UTI, prostate inflammation, bowel dysfunction [Herzog AR 1990]

UI in the Frail ElderlyUI in the Frail Elderly

Frail: decline in physical activity [Bortx WM 2002]

Frail elderly: >65, UI, can not go out without assistance, dementia, admitted to a long-term care facility [Fonda D 1998]

Risk Factors in Frail ElderlyRisk Factors in Frail Elderly

Multiple medical morbidities Immobility Cognitive impairment (dementia)

ScreeningScreening

Routine assessment for UI can be easily incorporated into the general history questions [Feneley RC BJU 1997]

Screening by risk factors Urge UI + Nocturia >2 + daytime voiding

frequency of < 2hr = 90% detrusor overactivity on UDS [Gray M, 2001]

Assessment of UI in the Frail Assessment of UI in the Frail Older AdultOlder Adult

History and symptom assessment Clinical and physical assessment Environmental assessment Identify possible diagnosis or clinical

impression

Potential Reverse CausesPotential Reverse Causes

Delirium, dementia, depression Infection (UTI) Atrophic vaginitis Pharmaceuticals Psychological, Pain Excess fluid (polyuria, edema) Restricted mobility Stool (constipation)

Behavioral TherapyBehavioral Therapy

AHCPR guideline Bladder training: strongly recommended for

urge and mixed incontinence and also recommended for stress UI

Pelvic floor rehabilitation: strongly recommended for stress UI

The first line of treatment [Fantl J 1996]

Nonpharmacologic Nonpharmacologic Management of UI in AdultsManagement of UI in Adults

Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive interventions

Lifestyle ModificationLifestyle Modification

Reduce risk factors Stress UI: smoking cessation,change body

position [Norton PA 1994], weight reduction [Deitel M 1988]

Constipation: good bowel hygiene Urge UI: caffeine reduction, selected dietary

and fluid modification No study support: bladder irritants, alcohol

[Wyman JF 2000]

Nonpharmacologic Nonpharmacologic Management of UI in AdultsManagement of UI in Adults

Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Devices Supportive intervention

Scheduled Voiding RegimensScheduled Voiding Regimens

Timed voiding Habit retraining Patterned urge response toileting Prompted voiding Bladder training

Nonpharmacologic Nonpharmacologic Management of UI in AdultsManagement of UI in Adults

Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive intervention

Pelvic Floor Muscle Pelvic Floor Muscle RehabilitationRehabilitation

Pelvic floor muscle exercise Vaginal weight training Biofeedback Electric stimulation Magnetic stimulation

Nonpharmacologic Nonpharmacologic Management of UI in AdultsManagement of UI in Adults

Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive intervention

Anti-incontinence DeviceAnti-incontinence Device

Intravaginal support device External occlusive device Intraurethral occlusive device Complex valved catheter External collection device Urethral catheter

Intravaginal Support DeviceIntravaginal Support Device

Pessary Support the bladder neck, relieve minor pelvic

prolapse and change pressure transmission Stress UI Estrogen replacement for postmenopausal

women

External Occlusive DeviceExternal Occlusive Device

A small single-use device that covers the urethral meatus for women

A penile clamp for men Need good manual dexterity Complication: periurethral irritation or penile

erosion

Intraurethral Occlusive DeviceIntraurethral Occlusive Device

Urethral plug A small single-use device that is worn in the

urethra to provide mechanical obstruction Used for stress UI in cognitively intact patient Complication: urethral irritation, hematuria,

UTI or migrate into bladder

Complex Valved CatheterComplex Valved Catheter

Intraurethral occlusive device with a unidirectional valve

Left indwelling for long period Must be inserted and removed by a clinician Being test for female stress UI, overflow UI Complication: urethral irritation, hematuria,

UTI

External Collection DeviceExternal Collection Device

Condom catheter with leg bag Used in men with urge, stress and overflow

UI and in those with functionally impairment More comfortable, less painful and less

restrictive than use of an indwelling catheter [Saint S 1999]

Risk for UTI, penile skin marceration

Urethral CathetersUrethral Catheters

Disposable, single-use catheter and indwelling catheters

Used for overflow UI Bedbound, mobility impairment and severe UI Clean intermittent catheterization is the

standard care of spinal cord injury [Perrouin-Verbe B 1995]

Indications for Long-term Indications for Long-term Indwelling CathetersIndwelling Catheters

Persistent overflow UI, symptomatic UTI or kidney disease

Surgical or pharmacologic intervention failed Contraindication for CIC Changes of bedding, clothing and absorbent

products may be painful or disruptive for p’t with an irreversible medical condition

Not healed grade 3-4 pressure ulcers Patients live alone without a caregiver

Nonpharmacologic Nonpharmacologic Management of UI in AdultsManagement of UI in Adults

Lifestyle or risk factors modification Scheduled voiding regimens Pelvic floor muscle rehabilitation Anti-incontinence devices Supportive intervention

Supportive InterventionsSupportive Interventions

Toileting substitutes and other environmental modifications

Physical and occupational therapy Absorbent products

Toileting Substitutes and Other Toileting Substitutes and Other Environmental ModificationsEnvironmental Modifications

Urinals, bedside commodes, elevated toilet seats

Used for patients with mobility impairment that make it difficult to reach a toilet in a timely fashion

Physical and Occupational Physical and Occupational TherapyTherapy

Gait and strength training Used for frail older patients with mobility or

manual dexterity impairments that make it difficult to reach a toilet and disrobe in a timely fashion

Absorbent ProductsAbsorbent Products

Reusable and disposable pads and pants system

Some products contain a polymer that absorbs urine and binds with urine, changing it into gel [Newman D 2002]

Used for all types of incontinence But never be used solely for the convenience

of the caregiver

Behavioral Therapy in Frail Behavioral Therapy in Frail EldersElders

Adequate fluid intake Bowel regularity Perineal hygiene Voiding every 2 to 4 hours Avoid caffeine in urge UI Toileting programs

Skin CareSkin Care

Perineal hygiene after toileting Skin dryness Comfortable clothes Skin ulcer: isolation cream, Duoderm,

Comfeel

Prevention of Excess Prevention of Excess DisabilityDisability

The two primary risk factors for UI among the frail elderly are immobility and cognitive impairment

Tailored programs that enhance physical mobility and cognitive function [Schnelle J 2000]

Optimal management of acute and chronic illness

Environmental modification Prosthetic support [Weindrug R 1991]

Algorithm -- I Algorithm -- I

Three-day bladder record, measure RU Determine which type of UI What trigger it Individual care plans Four goals: fewer incontinence episodes,

daytime continence, 24-hour continence, the prevention of skin breakdown and odor

Algorithm -- IIAlgorithm -- II

Behavioral interventions Ambulatory assistance Cognitively intact PFM training Passive exercise Goal one to goal three Goal four is reserved for comatose or very

debilitated patients