Chapter 1: Introduction

Incontinence has been regarded as a geriatric giant and a major health care problem among older adults. It is one of the most unpleasant and distressing symptoms an individual can suffer.

Let’s start with a case scenario

Case story

For those affected with incontinence problem

• Often feel embarrassed, ashamed and alone
• Hide their problem from society, their family and friends, even from themselves
• Seldom seek for medical advice or treatment

Prevalence of incontinence

Asia Pacific Continence Advisory Board Survey (APCAB) 1998

(Chin, 2001)

A local community continence promotion programme of elderly centres in 2000

Among 363 elderly women attended the program
40.8% reported urinary incontinence
(Hsia & Mok, 2001)

A local study in subsidized long-term care services in 2010

Among 5301 Chinese adults aged ≥ 60 in HK (average age = 80.4), who had completed an initial screening instrument:
45.7% of male and 45.6% of female participants reported urinary incontinence.
(Bai, Leung, Lai, Chong, & Chi, 2017)
Among elderly residents of nursing homes:
Occurrence of urinary incontinence has increased significantly over the past 20 years
23.3% in 1992
45% in 2003
54.1% in 2009
(The Hong Kong Polytechnic University, 2014)

International Continence Society (ICS) estimated 30-40% of >65 years in community has urinary leaking.
(Stenzelius et al, 2015)

From the above studies, you may find that:

• The prevalence of incontinence is increasing.
• Urinary incontinence is common for women and older adults.
• The rate is typically higher in institutions.

Possible reasons of the INCREASING trend of incontinence:

• Underestimated of the actual situation in the past decades.
• People may assume that incontinence is a normal consequence of ageing.
• People may be embarrassed by their incontinence or fear invasive testing, and thus, avoid evaluation.
• In primary health care clinics and hospitals, medical and health personnel rarely ask patients about urinary incontinence.
• People seldom initiate discussions about incontinence.
   (Poi, 1995)

5 myths of incontinence

Understanding continence and ageing

• Higher cortical function (social norm to keep dry)
• Awareness of need to empty (sensation)
• Bladder holding capacity to avoid social embarrassment
• Mobility (to toilet) and other self-care ability (e.g. undress lower garment)
• Contractibility of bladder and relaxation of sphincter for emptying

• Age-related changes in lower urinary tract
• Reduced mobility
• Impaired cognition
• Malnutrition e.g. dehydration and low-fibre
• Medication side effects (eg. sedation drugs, diuretics, cholinergic drugs)

Age-related changes in the lower urinary tract

Common features of urinary frequency/ incontinence

• Urinary incontinence without awareness
• Leaking of urine when coughing /sneezing
• Leaking of urine when urgency
• Nocturia (wake up from bed to void > 1 time during sleeping time)
• Bed wetting
• Frequency of micturition (>7 times/day)
• Weak stream

Warning signs

• Haematuria (blood in urine) - beware of urinary tract infection or structural pathology
• Difficulty in passing urine	These two are commonly associated with urinary retention or overflow incontinence
• Dysuria (pain during voiding)

Impacts of incontinence in older adults

Psychological impact of incontinence among older adults

• Discomfort
• Smelly
• Skin rash
• Bed sore
• Fall (urge to toilet prone to fall)
• Dehydration due to decrease fluid intake to prevent wet

• Loss of self-esteem and self confidence
• Dependent
• Worry (didn’t know how to manage)
• Embarrassing
• Depression

• Avoid social life
• Isolation due to don’t want the others know his /her condition

• Increase financial burden for absorbent products

➤ ➤ ➤ Affect quality of life! ➤ ➤ ➤

How they cope with?
(Sometimes, in a wrong way…)

Avoidance

• Long journeys (with others)
• Trips with friend
  → Social isolation

Planning

• Don’t drink water → Dehydration & concentrated urine will induce bladder irritation
• ‘Just in case’ (no urgency but go to toilet in order to prevent wet) → Reduces the ability to hold the urine if urinating too frequent
• ‘Toilet mapping’ (make sure the location of the toilet then plan the route)	→ Annoyance & anxiety
• Find seats near toilet / door
• Wear dark clothes (not easy to detect wet)
• Carry spare underwear

Cleanliness

• Frequent showering→ May cause skin irritation and bring to psychological burden
• Change clothes frequently→ Annoyance & anxiety
• Use of scents (cover the smell of urine)

Use of pads

• If know no toilet
  → Using toilet paper as a “pad” is NOT correct.
  Tips on choosing incontinence products will be discussed in Chapter 4.

Impacts on caregivers

• Stress
• Anger
• Impatient
• Frustrated
• Invading their privacy when take care of perineum or penis
• Distress
• Sleep disturbance
• Decrease intimacy
• Increase financial burden
• Affect social life
• Decrease quality of life

How can caregivers help the older adults and reduce stress?

1. Be empathetic

• Understand older adult’s worries, be patience and tact to ease the older adult’s anxiety. It also helps caregivers to reduce stress level as well.

2. Get a physical examination to see if the cause of incontinence is treatable

• Most conditions can be improved after medical problem had been solved.

3. Wear clothes that are easy to get on and off

• Slacks with an elastic waistband can be pulled down quickly.
• Enable older adult to get on the toilet faster and possibly avoid an accident.
• If caregivers have to help the older adult with cleanup, easy-off garments make it simpler for you to undress and re-dress them.

4. Watch the diet

• Avoid consuming caffeine e.g. coffee, tea, Chinese tea, chocolate and cold drinks, spicy foods and a lot of fresh or dried fruit.

5. Always be prepared

• Pack a small bag with supplies, e.g. incontinence pads, wipes, tissue and even a change of clothes in case an accident happens when going out together.

6. Adopt a matter-of-fact approach

• This technique can overcome an older adult’s shyness or embarrassment.
• Use reassurance and a straightforward manner: “Oh, that’s too bad you had an accident, but don’t worry. It happens to a lot of people. Let me help you get cleaned up and into some dry, comfortable clothes.”

7. Accept help

• Many caregivers who are taking all responsibility to take care of the older adults by themselves only.
• Encourage them to ask for support from the home care service e.g. bathing or house cleaning or escort for attending the appointment.
• Arrange some me-time to reduce the stress.

- End of Chapter 1-

Chapter 2: Urinary incontinence

Case story

An 80-year-old woman with mild dementia was admitted to the medical ward because of high-grade fever. She had confusion and unable to recognize that she was in the hospital. She was yelling and wanted to go home. Health care worker gave her the incontinence pad because she wet her bed all the night.

Types of urinary incontinence

• Transient incontinence
• Persistence incontinence

Transient incontinence

• Temporary, reversible
• Caused by an illness or a specific medical condition that is short-lived and quickly remedied by appropriate treatment of the condition and a disappearance of symptoms.

Causes:

DIPPERS

Persistent incontinence

• Stress incontinence
• Urge incontinence (Overactive bladder)
• Overflow incontinence (Incontinence associated with incomplete bladder emptying)
• Functional incontinence
• Mixed Incontinence

Stress incontinence

Stress Incontinence

Signs & symptoms:

• leaking of urine when coughing, sneezing and physical activities that increased the intra-abdominal pressure
• may be infrequent
• involves very small amounts of urine
• common in older women
• degree of stress incontinence: ranges from mild to severe

Causes:

• Sphincter weakness due to:

  - Lack of oestrogen → weakened supporting tissues and consequent hypermobility of the bladder outlet & urethra
  - Vaginal delivery will damage the pelvic floor muscle during delivery
  - Chronic cough will weaken the pelvic floor muscle
  - Chronic straining at stool
  - Obesity
  - Radical prostatectomy (surgical removal of the whole prostate gland for prostate cancer)

Management:

• Pelvic Floor Exercise
  

  
  Pelvic floor exercise

  - To improve the tone of the muscles in the pelvic floor which provide support to the urethra and bladder neck.
  - First line treatment for stress incontinence and combined stress and urge incontinence.
  - Useful for men after prostatectomy operation, where a degree of stress incontinence occur because of damage to the urethral sphincter mechanism.
  - Should be practiced regularly and daily. Apply when need!

• Biofeedback Therapy
  

  - Use of instrumentation to mirror psycho physiologic process that the individual is not normally aware of and that may be controlled voluntarily.
  - Help regain control over the muscles in the bladder and urethra.
  - Can be helpful when learning pelvic muscle exercises.

• Surgery (TVT/TOT)
  

  - Tension free vaginal tape is common and effective surgery nowadays.
  - Aims to support the mid-urethra and increase urethral resistance.

  
  Image source from: https://indigowomenscenter.com/urinary-incontinence-treatment/

Urge incontinence (Overactive bladder)

Frequent urination and overactive bladder

Signs & symptoms:

• Leakage arising from the ability to suppress an urgent desire to urinate
• Associated with large volumes of urine loss
• Symptoms of an overactive bladder

  - frequent urination (voiding every ≤ 2 hours)
  - urgency
  - nocturia (≥2 voids during usual sleeping hours)

Causes:

• Poor storage due to:

  - Detrusor overactivity
  - Idiopathic (didn’t find the actual causes)
  - Bladder outlet obstruction (enlarge prostate will irritate the bladder contraction)
  - Bladder disease
  - Neurogenic (poor DM control / stroke)

Management:

• Pelvic Floor Exercise
• Bladder training
  

  
  Bladder training

  - To restore the older adult with frequency, urgency and/or urgency incontinence to a more normal pattern of micturition.

• Caffeine limitation
  

  - To reduce irritant drinks will decrease the frequency and urgency of urination.

• Pharmacotherapy (anticholinergics)
  

  - To inhibit bladder contraction.
  - Common side effects:

  o dry mouth
  o blurring of vision
  o incomplete emptying of bladder
  o constipation
  o may also impair older adult’s cognitive function

  *Should be used with caution!

• Surgery (Botox injection)
  

  - Inject Botox into the muscle of the bladder to destroy the nerve ending to decrease bladder contraction
  - Need to repeat injection to maintain the effect

Overflow incontinence (Incontinence associated with incomplete bladder emptying)

• An over-distended bladder to a point where the elevated intravesical pressure overcomes the urethral resistance but in the absence of detrusor activity.
• Post voiding residual urine volume ≥ 200 mL

Causes:

- Bladder outlet obstruction

o Lower urinary tract symptomatology (LUTS)

Lower urinary tract symptoms

o Enlarging Prostate, i.e. Benign prostatic hyperplasia (BPH) in men
o Urethral stenosis in women

- Acontractile bladder e.g. Diabetic autoneuropathy

Management:

• Relieve obstruction
  

  - Perform TURP to remove bladder outlet obstruction
  - Dilatation is used to widen the urethral stenosis

• Treat/avoid constipation
  

  - Stool impaction → induce incomplete emptying of bladder.

• Review of medications
  

  - To reduce bladder contraction.

• Consider catheterization (Intermittent/indwelling)
  

  - Intermittent catheterization

  o is a feasible option in the management of poor emptying.
  o can be taught to the caregiver if older adult is invalid or has poor manual dexterity.

  - Indwelling catheterization

  o are always considered as a last resort in continence management.

Functional incontinence

Causes:

• Urinary leakage caused by:
  Functional factors

  - Failure to recognize the need to use the toilet (cognitive impairment)
  - Failure to remember to use the toilet (dementia)
  - Lack of motivation to use the toilet (depression)
  - Decreased ability to use the toilet (physical and mobility limitation, e.g. stroke or frailty)

  
  Environmental factors

  - Poor access to toilet

  When the toilet is too far away or has obstacles e.g. steps.
  - Lack of privacy

  When the older adult “being forced” to use bedpan or bedside commode with only a curtain to separate them from the view of others.

  
  - Unconducive toilet facilities

  Badly maintained toilets with foul odour or dirty seats discourages the older adult to “hang on”, this may lead to retention or incontinence.

  
  - Negative attitudes of caregivers

  If incontinence is accepted as part of aging and normal in the older adults, it becomes ignored. Minimal effort will be given to promote continence.

  
  - Unfamiliar environment

  Cognitively impaired older adults often become more confused with changes in environment and usually fail to locate the toilet even if they have been shown the way.

• Environmental factors are NOT associated with any pathologic condition of urinary system or voiding mechanism.

Management:

• Prompted voiding

  - a toileting program that combines scheduled voiding with "prompting" from a caregiver
  - to improve bladder control for people with or without dementia using verbal prompts and positive reinforcement
  - appropriate for older adults with all types of UI and in individuals who may have impaired cognitive function.
  - a local study: https://www.sciencedaily.com/releases/2014/01/140106132955.htm

• Timed voiding

  - a fixed time interval toileting assistance program that has been promoted for the management of people with urinary incontinence who cannot participate in independent toileting.
  - suggest to be practiced in residential care settings, especially for clients with cognitive impairment.

Before asking the older adult to put on a diaper, what else can we do?

Helping the older adults with incontinence

Helping the older adults with incontinence

Mixed incontinence

• A combination of stress and urge incontinence

Assessment of urinary incontinence

It’s not uncommon to see a patient who was admitted to a hospital would be put on a diaper to solve the problem of incontinence. However, should we ask the question ‘Does the patient has transient or persistence incontinence before giving him/her a diaper?’

continence assessment is necessary to understand the cause and make any decision on managing the problem of incontinence.

Assessment includes:

• History taking
• Physical examination
• Diagnosis
• Investigations

History taking

• Past medical history

  - medical conditions that may co-exist with or contribute to incontinence.

• Past surgical history

  - any post-operative complications from urethral dilation, TURP, bladder neck surgery or other urological history?

• Past obstetric history

  - no. of pregnancies, children’s birth weights, type of deliveries, menstrual status
  - women are particularly vulnerable to stress incontinence ∵ pelvic floor damage during child birth & post-menopausal hormone decline.

• Past gynaecological history

  - e.g. abdominal hysterectomy, vaginal hysterectomy, pelvic floor repair

• Current medication

  - For details, refers to DIPPERS: Pharmaceutic

• Onset of incontinence
   
• Common features on urinary frequency and incontinence (pls refer to Chapter 1)
• Precipitating factor (any leaking of urine at below situations?)

  - e.g. coughing, laughing, lifting, urgency

• Bladder awareness
• Incontinence aids (use aids for absorbing urine?)
• Bowel symptoms

  - Frequency, normal bowel habits, character (hard, palate, soft, loose, watery?), constipation, PR bleeding (any bleeding after bowel opening?)

• Amount and type of fluid intake

  - Be aware of the bladder irritating beverages e.g. alcohol, coffee, Chinese tea and cold drinks
  - Should NOT restrict fluid intake to avoid incontinence

• Psychological status

  - Any impaired mental function e.g. depressed, stressed or experiencing family or social problem

• Functional status

  - Examine and determine older adult’s mobility, manual dexterity and eyesight.
  - Restricted mobility may precipitate incontinence by limiting the ability to reach the toilet in time.
  - Manual dexterity is required for undressing upon reaching the toilet.

• Attitude towards incontinence

  - Attitude towards incontinence present a major problem in tackling it.
  - Passive acceptance of incontinence as an inevitable part of aging → affect compliance to the treatment plan.

Physical examination

• Palpation of the lower abdomen to reveal a palpable bladder.
• Vaginal examination

  - Examine the vagina to detect:

  o vaginal discharge
  o atrophic vaginitis/ urethritis
  o prolapse such as cystocele, rectocele & uterine prolapse

  - Examine the tone of pelvic floor muscles and the older adult’s ability to perform slow and fast twitch ability.

• Rectal examination

  - Observe for skin tags or haemorrhoids that might make defecation painful. A digital rectal examination is necessary to check for impacted stool, enlarged prostate or a lax anal sphincter.

Investigations

• Volume chart/ Bladder diary

  - the single most useful tool in assessing the older adult’s level of incontinence.
  - acts as a record to be interpreted with the other findings of the continence assessment and diagnosis and to plan care.
  
  
  

• International Prostate Symptom Score (IPSS)

  - It has 7 questions and provides a score ranging from 0-35. (https://www.hkua.org/IPSS/)
  - Identify the voiding or storage problems and from the total score can reflect the severity of lower urinary tract symptom.

• International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI short form)

  - It has 4 questions and provides a score range from 0-21. (https://iciq.net/iciq-ui-sf)
  - With the higher score indicating greater severity of symptom

• Urinalysis and culture

  - collect mid-stream urine for culture and microscopy

• Flow rate

  - It is a cheap, simple and non-invasive test.
  - Procedure: voids into a funnel attached to a transducer that converts the velocity of urine flow into a graphic curve.
  - Identify abnormal voiding pattern from the flow curve.
  
  
  Image source from: https://patients.uroweb.org/tests/uroflowmetry/

• Post voiding residual urine (PVRU)

  - It is done after voiding and is a reflection of bladder contractility.
  - Over 100ml is significant in older adults.

• Blood test

  - Renal Function Test (RFT): to detect any kidney problems and show how well the kidneys are working.
  - Prostate Specific Antigen (PSA): if high PSA showed abnormal prostate gland, need to exclude prostate cancer by further investigation.

• Abdominal X-ray

  - To rule out faecal impaction.

• Urodynamic study (UD)

  - If the causes cannot be confirmed from clinical sign and symptom, then perform UD.

• Cystoscopy

  - Look inside the urethra and bladder by the instrument.
  
  
  Image source from: https://patients.uroweb.org/tests/uroflowmetry/
  
  
   
  
  
   
  
   

Importance of early recognition of common problems

• Older adults often have more than one factor contributing to their incontinence.
• Be constantly alert for the common underlying problems which can cause urinary incontinence.
• Identify the signs and symptoms of UTI, confusion, chronic cough, impaired mobility, impaired manual dexterity, an enlarged prostate, the side effects of drugs and the existence of neurological disorders.
• Get support for early treatment.

- End of Chapter 2-

Chapter 3: Faecal incontinence

Types of faecal incontinence

Assessment

A full history is required because the development of faecal incontinence in the older adults can have many interacting causes.

History taking

• Past medical history: CVA, Dementia, DM?
• Past surgery history: Inflammatory diseases or bowel surgery
• Past obstetrics and gynaecology history
• Diet & fluid intake
• Oral/dental state
• Medications: Use of laxatives
• Mobility/manual dexterity
• Environment: Toilet facilities, access to toilet
• Mental status
• Previous bowel habits
• Bowel chart: Frequency, colour, consistency, volume, incontinence
• Sensation of desire to defaecate: Absent/ urgent/ unaware/ normal

Physical examination

• Observe perineum for skin tags /haemorrhoids/faeces around anus/skin condition
• Rectal examination for anal tone, faecal loading or any pain or discomfort
• Bowel sounds: no bowel sound will consider bowel obstruction
• Abdominal palpitation: any mass or abnormal?

Other investigations may include

• Anal ultrasound
• Abdominal x-ray

Prevention of faecal incontinence

• Environment

  - Defecation is a complex process, involving the autonomic nervous and the use of voluntary control. People prefer to defecate in private.

• Adequate fluid intake

  - If poor hydrated, more water will be absorbed in the large intestine in an attempt to maintain fluid level, the faeces become dry and hard.

• Adequate fibre intake

  - Add sufficient bulk to stimulate peristaltic action.

• Increase mobility to increase peristaltic action
• Cognitive awareness for bowel training
• Medications

  - Use of medications with care, many drugs has unintended side effect to cause constipation.

Constipations has long been associated with impaction and is the most common cause of faecal incontinence.

Please refer to MOOC 8 Bowel Changes for more information.

- End of Chapter 3-

Chapter 4: Continence Management in Long Term Care

The important roles of nurses in managing incontinence

• Advocator

  - advocate for health and well being

• Care coordinator

  - collaborate multi-disciplinary professionals for care plan

• Educator

  - educate the older adults, their relatives and other caregivers to manage incontinence problem

• Professional caregiver

  - early detection
  - perform assessment and diagnostic tests
  - administer treatment
  - monitor the result of the care plan

Prevention of urinary incontinence in nursing home

Reflection
Think about

If you were the resident of long term care, would you like to wear a diaper?
As caregivers, should we give diapers for our clients as the first step of care for the prevention of urinary incontinence?
Could we use alternative in a hospital setting or nursing home?
How could we respect older adults’ dignity?

We have the following strategies for prevention of urinary incontinence.

Improving the environment

• Ensure the privacy and safety
• Provide each resident with an appropriate chair
• Provide each resident with a bed of the correct height
• Provide railings and bars to help residents to reach and use the toilets safely and without fear
• Provide lighting to help residents to reach and use the toilets safely and without fear
• Provide signs to help residents reach the toilet without losing the way and recognize the correct door when they arrive
• Ensure the floor surface helps residents reach the toilet without falling and without fear
• Provide simple clothing that helps residents go to toilet easily on their own
• Provide residents with toilets that are clean and acceptable condition

Encouraging good bladder habits

• Adequate fluid intake
  

  - make an assessment of how much fluid the residents are drinking each day
  - aware of contraindication in particular cases.

• Avoid bladder-irritating beverages, e.g. Chinese tea, coffee, tea, cold drinks
• Educate the residents to stop ‘just in case’.
• When the caregivers help residents to go to toilet, reassure them that there is plenty of time and encourage them to empty their bladder completely.
• Identify continent residents who are struggling to get to the toilet, help them and at the same time encourage them to ask for help when next they go to the toilet.
• Encourage residents to tell you when they are constipated so that you can help them by increasing fluid and fibre intake and ensure they get more exercise.
• Encourage pelvic floor exercises.
  

  - pelvic floor supports the bladder and urethral sphincter.
  - plays a vital role in maintain good urethral closure → prevent urine leakage

Image source from: edemenca.si

Care for people with dementia and incontinence

Problems of people in the later stages of dementia:

• not realizing they need to urinate
• forgetting to go to the bathroom
• not being able to find the toilet

To minimize the chance of accidents, the caregiver should:

• Avoid giving drinks like caffeinated coffee, tea, and sodas, which may increase urination. But don’t limit water.
• Keep pathways clear and the bathroom clutter-free, with a light on at all times.
• Make sure you provide regular bathroom breaks (Timed voiding).
• Supply underwear that is easy to get on and off.
• Use absorbent underclothes for trips away from home.

For moderate and severe dementia cases, it’s hard for them to manage functional incontinence by learning pelvic floor exercise and bladder training. Timed voiding may consider as a solution.

Conservative treatment is preferred: skin care and use of continence aids are recommended.

Skin care

Individuals with intractable incontinence are often immobile and at major risk for skin breakdown. Skin care is very important in day-to-day care.

• Assess perineal skin condition and integrity regularly
• Maintain good hygiene to prevent skin breakdown and maintain skin integrity.



- Esp. immobile → at major risk for skin breakdown
- Thorough cleansing of the entire genital area at least twice a day.
- Gentle cleansing of the skin after each soiling.
- Avoid force and friction during cleansing.
- Patted dry skin with a soft towel gently but thoroughly after cleansing.

• Take bath or shower daily especially in hot season.
  

  - Use water and mild unperfumed soap
  - Avoid soap if dry skin, dermatitis or pruritus. Strong soap may destroy sebum, provoke skin reaction and cause discomfort
  - Avoid bubble bath ∵ cannot rinse the skin completely

• Apply a moisturizing lotion or cream for dry skin.
  

  - Use a moisture barrier product (e.g. barrier cream or castor oil) if skin irritation is present or at risk.
  - Re-apply the moisture barrier product after each incontinent episode and every 12 – 24 hours.

• Avoid using talcum powder ∵irritate and tend to form lumps when dampened by urine causing encrustations in the groin skin folds.
• Replace absorbent incontinent product frequently to keep skin dry. Avoid using plastic pants.
• If the skin is becoming sore, factors other than the incontinence should be investigated:
  

  - Sensitive to the materials of incontinent pad or appliance, e.g. latex of a penile sheath
  - The pad may be too rough.
  - Appliance may be too tight.
  - Plastic in conduct with wet skin.
  - Candida infection.

• Minimize skin injury caused by friction or shearing forces through proper positioning, turning and transfer techniques.

Use of continence of aids & appliances

• aim to minimize the effect of incontinence & enhance the quality of life
• assessment is needed before use

Assessment

• The incontinence itself: Type, amount, pattern and timing, precipitants of incontinence
• Mobility: The chair bound/ bedbound/ ambulant patient have different needs
• Manual dexterity: If dexterity is poor, some products cannot be managed easily or independently
• Local anatomy: Features of genital skin condition or anatomy may indicate certain items
• Mental function: A confused or demented person may not be able to manage a complex aids
• Personal hygiene: Washable and reusable items are inappropriate for those unlikely to wash them properly
• Personal preference: Some people take a like or dislike to certain products
• Availability: An easily and reliably available is important
• Domestic facilities: People with poor facilities for washing and drying may find using washable products difficult
• Financial considerations

Selection of aids & appliances

How to select incontinence products

Selection principles

• Can maintain patient’s dignity and enable him/her to achieve “social continence”
• Can contain the excreta completely to prevent any leakage and disguise any odour.
• Be comfortable to wear and protect vulnerable skin from soreness, chafing or pressure sores.
• Be easily managed by older adults and caregivers.
• Be easy either to dispose of, or wash and clean, as appropriate.
• Be reasonably priced and easily available.

Absorbent products

• Can be used by both sexes.
• In a wide range of shapes, sizes and degree of absorbency to cater individual’s needs.
• Available in:
  

  - Two pieces system- involving the part and pads to keep in position
  - One piece system- the pad is incorporated in the part itself

Types of incontinence aids

• Disposable pads and reusable pants
• Disposable diapers
• Disposable mobile pants

• Hand-held urinals (Male & female)
  

  (Male)

  (Female)

• Bedpans
  
• Commodes
• Penile Sheaths (Paul’s tube)
  

  - Adhesive coated on sheath lining to make it adhesive
  - Foam strip coated with adhesive on both sizes for internal fixation of sheath
  - Contraindication for penis sheath

  o Retracted penis
  o Skin sensitively
  o Lack of manual dexterity
  o Mental capacity – difficult in putting it or without the help of a caregiver

• Dribble pouch
  

  - useful for those with dribbling incontinence

• made of cellulose padding with a waterproof backing for protect the mattress

• Smart Diaper
• Portable toilet frame
• Toilet seat lift
• Shower commode chair
• Foldable shower chair
• Wearable device for incontinence

Gerontechnology products for incontinence

Changing diapers and use of urinary sheath

Changing diaper in a standing position

Changing diaper in a lying position (Assisted by 1 and 2 persons)

Wearing incontinence pant

How to use urinary sheath

Multidisciplinary care approach

• Nurse

- acts as a case coordinator
- nursing management

• Physician

- medical assessment
- diagnosis
- medical treatment for revisable condition

• Physiotherapist

- rehabilitation on mobility
- pelvic floor training

• Occupational therapist

- prescription of aids and appliances to enhance continence ability
- environmental modification
- functional transfer training
- manual dexterity training

• Social worker

- counselling emotional unstable or depressed older adults
- referral on community health care services
- caregiver support group

- End of Chapter 4-

Chapter 5: Indwelling urinary catheter care

Indications for indwelling urinary catheter

• Severe illness - monitoring of urine output is necessary
• Post-operative drainage after urological or gynaecological surgery
• Terminal ill - quality of life will be improved
• Intractable urinary incontinence - alternative management has been unsuccessful
• Neurological deficits leading to incomplete bladder emptying
• For those having bladder outlet obstruction

Indwelling urinary catheter should be used after a thorough assessment of individual person needs and after considering other potential alternatives.

Image source from: www.roswellpark.org

Care of the catheter

Care of catheter drainage system

Frequency of changing catheter

• Life span of the catheter depends on catheter material and the recommended period by the product company
• Routine changing of the catheter at fixed time intervals
• Interval for changing catheter should be individualized for each person
• Catheters should be changed proactively according to the individual’s usual pattern of catheter life rather than replaced after they are blocked
• Change the catheter immediately if:

  - blockage

  - expulsed catheter

  - damage catheter

Frequency of changing drainage bag

• Changing bag when:

  - changing catheter

  - dirty and smelly

• Too frequent changes will incur:

  - unnecessary expense

  - unnecessary disconnection of the closed drainage system

Removing catheter

• Review the reason of catheterization and older adult‘s condition regularly and remove the catheter as soon as possible
• Be aware of high incidence of:

  o    recurrent retention of urine

  o    incomplete emptying the bladder

  o    recurrent urinary tract infection

  o    urinary incontinence

• After removing the catheter, check post voiding residual urine to assess the ability to empty the bladder effectively
• Maintain high fluid intake and avoid constipation

- End of Chapter 5-

Reference