Continence Care: Enhanced Protocols for Assisted Living.

As seniors choose to age in place, assisted living focuses on continence care--and now has a source of expert guidance

Incontinence is an increasing problem in assisted living communities as seniors choose to age in place, creating a population of increasingly frail elderly. If the condition becomes unmanageable, a resident might be asked to leave the community where he planned to spend the rest of his days.

This is true for several reasons:

1. As this population advances in years, it also must contend with an increasing number of chronic illnesses. Besides age, other at-risk conditions that might precipitate incontinence are decreased mobility and possible effects of medication reactions, which can dramatically impact a resident's quality of life. Social withdrawal, loss of sleep, depression and embarrassment are some of the negative consequences that can result from ignoring the problem. When this happens, not only is the resident upset, but the frustration also manifests itself in the family; they feel guilt and confusion about their loved one's loss of function and might decide to place the resident in a skilled nursing facility.

2. Assisted living management wants residents to take responsibility for personal continence by following proper dietary habits and regimens to support a healthy bladder. Frontline caregivers need to be trained to assist the resident to spot problems or episodes of incontinence and provide encouragement. Caregivers might have to help the resident adjust to a time-voiding schedule and provide toileting assistance, if necessary.

3. Through a nationwide survey, the National Association For Continence (NAFC) determined that at least one-third of responding assisted living facilities claimed to have a continence program in place, while another one-third of the respondents expressed the need for enhancements to their existing program or help in establishing one. This suggests that there are gaps or inconsistencies in how continence care is delivered in this setting.

4. The assisted living concept was created according to "social, not medical" models. Therefore, when the assisted living community was conceptualized, it was staffed by people to provide service, not medical care. Because of the desire of residents to age in place, the lines have blurred between providing service and the need to deliver healthcare.

Recognizing a growing need for caregiving guidance, the NAFC, a nonprofit organization dedicated to improving the quality of life for people with incontinence, has released the "Blueprint for Continence Care in an Assisted Living Setting."

"The 'Blueprint' is based heavily on current continence guidelines developed by the Agency for Health Care Policy and Research [AHCPR], now known as the Agency for Health Care Research and Quality [AHRCRQ] and the American Medical Directors Association [AMDA]," according to Nancy Muller, executive director of the NAFC. "We took current practices and accepted clinical guidelines and put them in a context appropriate for the assisted living community."

Developed by a blue-ribbon task force and endorsed by healthcare associations, such as The Alzheimer's Association and American Geriatrics Society, the NAFC program covers both clinical assessment and continence management of assisted living residents and the training of their caregivers. NAFC research indicated that the most wanted elements of a continence care program in this field are information and self-help pamphlets for residents and immediate family members and self-administered tutorials for staff training. Advice on subjects, such as pelvic exercises and easy-to-remove clothing, is intended to inspire the resident to take an active interest in managing his/her condition. The "Blueprint" also recommends ways to maintain a healthy bladder, including diet, toileting habits and weight control. Information about treatment options includes behavioral modification, pharmacologic intervention, medical devices and, as a last resort, surgery.

According to Muller, the "Blueprint" is based on the willingness of assisted living communities to educate residents and train staff in the provision of continence care. "The survey's message was loud and clear," she said. "Supervisors at the staff level indicated that they really want their residents to take responsibility for their own wellness. They want education for residents in diet and daily habits that promote a healthy bladder. They want family members to be educated in preventing incontinence, in reversing transient [temporary] incontinence and in ways to address chronic, intractable incontinence.

In sum, no longer can the assisted living environment be content with simply providing resident services. It now faces increased government scrutiny and growing consumer empowerment in the caregiving arena. Adopting established continence standards might preempt government interference by demonstrating, through voluntary adherence, the industry's willingness to be self-regulating.

Of more immediate benefit to the facility: possibly higher occupancy rates. Happy residents generate referrals, and positive marketing of the program's success will attract new residents. "But be aware," said Muller, "that if an assisted living community offers a continence care program in its marketing materials, it has to be backed with expert, established guidelines. The 'Blueprint' can be a valuable tool to help put teeth in a marketing program and demonstrate the facility's commitment to this issue."