An article by Laura Aitami Gil Santana,
Physiotherapist specialized in Oncohematology, Urogynecology and Obstetrics
Member of the Physiotherapy Commission in Urogynecology and Obstetrics of the COFC,
and Gara Montserrat Dorta Martin,
physiotherapist specializing in musculoskeletal physiotherapy and therapeutic exercise
Secretary of the Commission for Physiotherapy in Geriatrics and Gerontology of the
The population is aging, but life expectancy is increasing with a sharp decline in mortality which represents a great success of the society. However, hospital morbidity has increased, with genitourinary diseases among the top 10 diseases causing hospital care. Taking into account these data extracted from the it can be predicted that We are living and we will live in the coming decades a stage of aging on the risewhere the dependency rate will also increase, which will inevitably imply an increase in spending associated with aging, in health and social resources.
Fecal and urinary incontinence causes a series of associated problems in older people that affect their quality of life
With aging, there is the morphological and physiological deterioration in all the tissues that at the level of the anatomophysiological structures that make up the genitourinary system and pelvic floor, cause, together with the multi-pathologies that are usually concomitant due to age, added to the increase in drugs, cause this incontinence (urinary or fecal) to be aggravated in the elderly. The elderly with urinary or fecal incontinence will present a series of consequences and associated problems.
The fact that incontinence is considered a geriatric syndromeindicates the relevance of this problem on the life of the person, so great relevance and more so if we add the consideration that, according to the WHO, the health of the elderly is measured in terms of function and not disease; Therefore, geriatric syndromes seem to better predict quality of life and/or mortality than the presence or number of medical diagnoses. And this, without including the rest of urogynecological and anorectal dysfunctions.
What is incontinence?
Incontinence is understood as the lack of continence or involuntary loss of, which in the case of the urinary is urine and in the fecal feces or gases. Urinary incontinence episodes can be transitory due to multiple psychological or organic causes, which usually disappear once the cause that caused the disease is restored. However, can be chronically established and here we include those that persist for a long period of time.
Therefore, it can be said that incontinence, correctly diagnosed or not, is cause a series of problems added to the underlying pathologies of the elderly as they are a deterioration of the quality of life, since it limits personal autonomy, causing serious psychological implications, the person perceives it and lives it as a limitation in his life, both at work and socially, causing him a emotional burden, distorting his body image and loss of self-esteem, and causing emotional disorders such as anxiety, stress and depression and social as social isolation and decrease in healthy physical life with inactivity and sedentary lifestyle.
Old people deserve special consideration as all types of UI/FI increase with age and generally coexist with other health problems that make them require specific therapeutic interventions. For this reason, it is of great importance from the pathophysiological point of view, being an important challenge for health care to achieve a correct diagnosis with a rapid, precise and complete approach both by the multidisciplinary professional team. as well as the family environment or caregiver, necessary in order not to reduce the quality of life of the elderly patient.
Action objectives
One of the main objectives of action of this multidisciplinary approach (with a strong level of evidence) would be achieve unify criteria for action in urinary incontinence during hospital admission to reduce the occurrence of adverse events of urinary incontinence in hospitalized patientswhose specific objectives could be: prevent skin lesions and urinary infections, reduce the risk of falls, increase the level of self-esteem and autonomy of the patient.
To avoid complications, it is necessary to make an assessment of the patient, making a record of the characteristics of the UI/FI, the factors that influence itcomplete physical examination of the patient, since according to some studies the presence of incontinence would not be related to the loss of physical capacity and it would be necessary to know what is the cause that produces it (typify incontinence), know their environmental environment and their social and family situationso that the therapeutic approach would be based on the cause: and it must be adequate and realistic, setting the objectives within the hospital, home or institutional environment, this management of incontinence being favorable to self-care.
Once diagnosed, the approach will be decided taking into account mainly the degree of affectation in the quality of life, the objectives of the person and their environment; as well as polypathology and polypharmacy, if present.
In the assessment of the patient’s incontinence by the professional, according to the evidence collected in the «» will have to:
- Obtain incontinence history.
- Daily fluid intake (amount, times, types), (Level IV)
- Surgical medical history that favors incontinence (stroke, diabetes, heart failure, bladder surgery, etc.) (Level IV)
- Check if the patient’s medication has an impact on incontinence. (Level IV) and Avoid medications that may contribute to UI. (Level I)
- Establish cognitive and functional capacities of the patient. (Level III)
- Check environmental or behavioral barriers that may hinder evacuations (proximity, lighting, staff aptitude). (Level III)
- Suggest analyzing the urine to determine the existence of infections. (Level IV) and avoid indwelling urinary catheters whenever possible to avoid the risk of urinary tract infections (UTIs). (Level I)
- Apply an individualized prompted evacuation plan based on the patient’s needs. (Level Ia)
- Implement a training program for induced evacuation. (Level IV)
- Promote the knowledge of the health professional or caregiver, about the resources of continuous assistance. (Level IV)
- Address incontinence from a multidisciplinary perspective. (Level IV)
- Develop an individualized plan of care using the data obtained from the history and physical examination, and in collaboration with other team members. Implement restroom schedules as needed. (Level I)
- Aim for weight loss as a long-term goal in patients with a body mass index (BMI) greater than 27. (Level II)
Evaluation of urinary incontinence:
- Document the presence/absence of UI for all patients on admission.
- The nurse collaborates with members of the interdisciplinary team to determine the type of UI and the possible etiologies of the UI. (Level I)
The approach to urinary or fecal incontinence can be:
- Conservative treatment: In the UI/IF it can be done directly and/or through the people responsible for their care in the case of dependent people and their choice will depend on the underlying cause, its severity, as well as the cognitive level of the patient. Should include:
- A) Educational and behavioral therapies: Both the patient and the person who attends or cares for him. They are the first line of treatment. This part of the treatment consists of educating the patient/caregiver, to understand the micturition and defecation rhythms, for which their frequency is analyzed using a micturition/defecation calendar, the functioning of the bladder/digestive system, digestion and defecation. According to the information obtained in the «Guide to Good Practices in Patients with Urinary Incontinence» give as:
General recommendations for patients with incontinence, by the multidisciplinary team (4):
- Monitor fluid intake (weak) and maintain an appropriate hydration program.
- Limit bladder irritants in the diet. (Level IV)
- Adjust the consistency of the feces, with the recommended dietary guidelines depending on whether it is a UI/IF.
- Modify the environment to facilitate continence. (Level IV)
- Prevent skin breakdown by providing immediate cleansing after an episode of incontinence and using barrier ointments recommended by your doctor. (Level II)
- Use absorbent products that best meet the preferences of patients, staff, and facilities, keeping in mind that diapers have been associated with UTIs
- Offer prompted voiding to adults with incontinence and cognitive limitation. (Strong rec.)
- Offer bladder training as a 1st line therapy to adults with UUI or MUI. (Strong rec.)
Weight loss and exercise are recommended for obese women with UI. Weight loss and exercise improved UI in obese women without obvious harm. (Strong rec., moderate-quality evidence).
Hygienic-dietary recommendations:
- Ensure adequate fluid intake and minimize the consumption of (strong) alcoholic or caffeinated beverages, whenever possible. (Level III)
- Management of aggravating health/lifestyle issues: monitor blood glucose levels, address overweight/obesity(strong), and quit tobacco use(strong).
- Wear comfortable clothing to facilitate urination/defecation in emergency conditions.
- Control recurrent urinary infections.
Behavior Modifying Techniques
These techniques They help, depending on the type of incontinence, to improve or maintain continence. In the case of patients with mild or severe cognitive impairment, it will be essential to have the collaboration of the main caregiver or caregivers to jointly establish the design of guidelines and routines according to the person’s situation. An attempt will always be made to respect their autonomy and encourage continence to the extent possible.using other types of strategies to facilitate its implementation (such as visual tips, service signage, lighting correction to access it, etc.).
- Bladder reeducation: Includes a whole series of guidelines for urination control in which it is a question of achieving a micturition habit training in order to delay the sensation of urination urgency or urination and recover lost control. It is necessary to plan the urination to be performed and control of fluid intake. Different strategies can be used with the patient:
- Perform urination according to a schedule or frequency determined by a voiding diary, with specific education, motivation and instruction to reduce…