Basic guidelines for the nursing home staff.

Incontinence management is laid out in the MDS/RAP-it's all in knowing how to use them

The nursing home resident whose activities or dignity are compromised by incontinence and diapering has every fight to expect a thorough evaluation and treatment program. Urinary incontinence assessments are now mandated by the OBRA Minimum Data Set (MDS). But nursing homes still struggle with issues of practicality, staffing, motivation, and reimbursement when deciding how far to go to diagnose and treat incontinence.

For example, a goal of eliminating all incontinence in a nursing home is an unrealistic, impractical, and perhaps even undesirable one. Few would dispute the inappropriateness of subjecting a bedridden end-stage Alzheimer's patient to a pelvic examination to rule out atrophic vaginitis. The attitude that it's pointless to try to change the continency status of a 90-year-old nursing home resident is prevalent, but needs to be changed.

Moreover, the most important consideration must be whether or not a workup and treatment will make a difference to the resident and his or her family. Being able to institute appropriate evaluation and management strategies in the nursing home has not been easy. One technique to ensure that proper assessment and management occur is to search the staff for a single person - probably an RN with a special interest in incontinence. Such a motivated person will be more likely to follow through than the staff member merely assigned the task. That nurse should be responsible for the preliminary incontinence evaluations, which entails understanding the MDS, applying the RAP, delegating responsibilities, making sure programs or treatments are followed through, and knowing when to ask for advanced consultation.

Physicians, in turn, are more likely to be responsive when an informed, knowledgeable staff member familiar with the MDS triggers and RAPs can explain the reasons for requested workups or treatments. The nurse, for example, can explain that an order for compression stockings may help resolve the pedal edema that is contributing to a particular resident's incontinence.

Identifying the Underlying Causes

Too often, however, pressure stockings aren't ordered or medications aren't changed because the staff tends to deal with the symptoms of incontinence without looking for underlying causes. This band-aid approach also increases the chances of missing an underlying, potentially serious condition.

The MDS triggers identify most of the conditions that cause or contribute to incontinence and the nurse can simply look through the MDS for those triggers. Some of these, such as fecal impaction, can be readily addressed. If the incontinence persists, a physical examination and thorough history, including the duration and frequency of incontinence, medications, and previous treatments, is the first step in a complete assessment. The next step is to differentiate between the transient causes of incontinence, which can often be rapidly and easily reversed, and the more permanent, established forms.

With the exception of urinary tract infections, transient forms of incontinence are usually identifiable with a history and physical. The involvement is generally outside the lower urinary tract and includes such conditions as fecal impaction, depression, immobility, heart failure, diabetes, and medications such as diuretics, sedative/hypnotics, anticholinergics, alpha blockers, stimulants, and antipsychotics.

If incontinence persists after treating the underlying condition or modifying the drug regimen, further investigation is needed. In women, this involves a pelvic exam to evaluate for atrophic vaginitis. This is an especially sensitive area. The feasibility of performing a pelvic exam on a 90-year-old woman who hasn't had such an exam in 60 years raises issues of practicality and/or discomfort to the resident. It's important to proceed only if the resident wants such an exam.

Certain lab tests - all detailed in the MDS - may also be helpful at this time: vitamin B 12 level, BUN, creatinine, urinalysis, blood glucose and calcium. If, for example, the glucose is high, causing increased diuresis, treatment of the diabetes may improve the incontinence.

The RAP provides an algorithm for established causes of incontinence by taking the nurse through potential urethral and bladder causes and suggesting simple clinical tests for evaluation. There are certainly more sophisticated diagnostic tests available in a hospital or urologist's office, but these RAP assessments are perfectly appropriate for the nursing home setting.

Urethral problems manifest as stress incontinence or overflow incontinence. Stress incontinence can be diagnosed with a simple clinical stress test. With a full bladder (at least 200 mls) the resident is asked to stand, relax, and cough vigorously. An instantaneous leak is a positive result. Stress incontinence is far more common in women, but can occur in men if they had prior urethra/surgery or radiation. Overflow incontinence, especially in men with a urethral blockage, should be referred to a urologist to rule out an enlarged prostate.

For the mentally intact resident, stress incontinence can often be managed with Kegel exercises. Biofeedback may prove to be a valuable aid in teaching these exercises. For residents who don't respond to the exercises, surgical correction should be considered.

A negative stress test suggests that the problem is bladder-related. Measuring voided volume and post-voiding residual helps to differentiate between uninhibited bladder (urge incontinence) and an underactive bladder. A post-voiding residual greater than 400 mls indicates an underactive bladder. If the resident voids 100 mls, for example, and leaves 150 to 200 mls, they probably have an uninhibited bladder rather than an obstruction.

Urge incontinence can be managed with bladder retraining or prompted voiding in residents without significant mental impairment. Medications, such as bladder relaxants or anticholinergics, may also be useful. Taking advantage of side effects of some medications, such as those used to treat depression, may provide the needed help for urinary incontinence without putting the resident on additional drugs.

Underactive bladder is often difficult to treat. To date, there are no drugs available to increase bladder contractility. Residents with underactive bladder without infection or significant retention can simply be monitored. But those with recurrent infection or urinary retention that may lead to reflux or possible kidney damage may require intermittent or chronic catheterization.

While acknowledging a large number of elderly have weak or poorly contractile bladders, the RAP recommends that residents-especially men-with a post-voiding residual greater than 100 ml be referred for a kidney ultrasound to rule out obstruction. The reason for this vigilence is that in men, the large residual urine may be related to the prostate and ultimately cause hydronephrosis and kidney failure. This may produce more referrals than needed. But the staff should not be afraid to refer for expert consultation, is needed. Excess referrals are preferable to missing a potentially life-threatening condition.

Furthermore, incontinence with hematuria in the absence of infection, pain upon urination, hard nodules found during a digital rectal exam, or abnormal lab values may be secondary to bladder cancer, bladder stones or other serious conditions. It's important that staff recognizes cases and institutes referral.

In summary, the MDS and RAP provide the tools for investigating causes of incontinence in a nursing home resident. Once these tools are mastered and implemented, great strides will have occurred toward improved care.

Dr. Brandeis is an Instructor in Medicine at Harvard Medical School's Division of Aging. He is also a geriatrician at the Hebrew Rehabilitation Center for Aged and at Beth Israel and Brigham and Women's Hospitals, Boston.